Miami Dade College, Miami - NURSING 660Safety Infection control 4000. All Questions and Answers.

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To prepare the community for the possible threat of anthrax, a nurse must teach that: 1. immunizations can prevent anthrax. 2. blood and body secretions can transmit anthrax. 3. physicians use ison... iazid (INH), rifampin (Rifadin), and pyrazinamide to treat anthrax. 4. anthrax can infect the integumentary, GI, and respiratory systems. A client with moderate Alzheimer's-related dementia is being prepared for discharge. What statement by the caregiver demonstrates that discharge teaching about client safety has been effective? 1. "I should encourage him to be active and do as much as he can on his own." 2. "Showering by himself is fine as long as he remains seated and holds tightly to the safety rails." 3. "I need to place signs in each room to help remind him where he is." 4. "Someone should supervise him at all times." While ambulating, a client who had an open cholecystectomy complains of feeling dizzy and then falls to the floor. After attending to the client, a nurse completes an incident report. Which action by the nurse should the charge nurse correct? 1. Documenting the incident factually in her nurses' notes 2. Submitting the incident report to the appropriate hospital administrator 3. Notifying the physician of the incident and the client's condition 4. Making a copy of the incident report for the client A nurse is teaching a client with a long leg cast how to use crutches properly while descending a staircase. The nurse should tell the client to transfer body weight to the unaffected leg, and then: 1. advance both legs. 2. advance the unaffected leg. 3. advance the affected leg. 4. advance both crutches. A client is in Buck's traction after fracturing his right hip. The nurse should include which action in the care plan? 1. Removing the weights once every shift2. Maintaining the bed in the knee-Gatch position 3. Keeping the client in semi-Fowler's position 4. Maintaining correct body alignment The nurse-manager of a 20-bed coronary care unit is off duty when a staff nurse makes a serious medication error. The client, who received an overdose of medication, nearly dies. Which statement accurately reflects the nurse-manager's accountability? 1. The nursing supervisor will notify the nurse-manager at home. 2. The nurse-manager is off duty; therefore, she need not be notified. 3. The nurse-manager should be informed when she returns to duty. 4. The nursing supervisor decides to call the off-duty nurse-manager if time permits A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do? 1. Check for an apical pulse. 2. Suction the client's artificial airway. 3. Increase the oxygen percentage. 4. Ventilate the client with a handheld mechanical ventilator. A nurse places a client in full leather restraints. How often must the nurse check the client's circulation? 1. Once per hour 2. Once per shift 3. Every 10 to 15 minutes 4. Every 2 hours A nurse uses Nitrazine paper to determine whether a pregnant client's membranes have ruptured. If the membranes have ruptured, the paper will turn which color? 1. Pink 2. Blue 3. Yellow 4. Green A client in the manic phase of bipolar disorder arrives at the outpatient psychiatric clinic. To help the client manage a manic episode, the nurse should suggest that she:1. go shopping with a friend. 2. read a book in a quiet room. 3. reorganize a kitchen cabinet. 4. play a game with a few friends. A nurse realizes she is 1 hour late in administering a dose of medication for a 4-year-old child. She gives the medication immediately, and assesses the child. The child isn't harmed by the delay. Which action should the nurse take next? 1. No further action is necessary. 2. The nurse should notify the physician of the error. 3. The nurse should follow facility procedures for reporting an error. 4. The nurse should document a medication error in the client's chart. A client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes the highest priority in this client's care plan? 1. Disturbed sensory perception (visual) 2. Dressing or grooming self-care deficit 3. Impaired verbal communication 4. Risk for injury A nurse prepares to measure a client's blood pressure. What is the correct procedure for measuring blood pressure? 1. Wrapping the cuff around the limb, with the uninflated bladder covering about onefourth of the limb circumference 2. Measuring the arm about 2″ (5 cm) above the antecubital space 3. Wrapping the cuff around the limb, with the uninflated bladder covering about three-quarters of the limb circumference 4. Using a bladder that is 6″ (15 cm) long. An assessment of a client's orientation is best obtained by: 1. asking the client's name, where he lives, and what time it is. 2. asking the client to repeat a series of three digits spoken slowly. 3. pointing to common objects and asking the client to name them.4. using the Glasgow Coma Scale and computing the score. When preparing a client for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis? 1. Obstruction of the appendix may increase venous drainage and cause the appendix to rupture. 2. Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix. 3. The appendix may develop gangrene and rupture, especially in a middle-aged client. 4. Infection of the appendix diminishes necrotic arterial blood flow and increases venous drainage. When caring for a client with severe impetigo, the nurse should include which intervention in the care plan? 1. Placing mitts on the client's hands 2. Administering systemic antibiotics as ordered 3. Applying topical antibiotics as ordered 4. Continuing to administer antibiotics for 21 days as ordered A physician orders meperidine (Demerol), 1.1 mg/kg I.M., for a 16-month-old child who has just had abdominal surgery. When administering this drug, the nurse should use a needle of which size? 1. 18G 2. 20G 3. 23G 4. 27G A nurse is to collect a sputum specimen from a client. The best time to collect this specimen is: 1. early in the evening. 2. any time during the day. 3. in the morning, as soon as the client awakens. 4. before bedtime.An infant requires cardiorespiratory monitoring. A nurse must locate and clean the necessary equipment, move it into the infant's room, and secure it to the bedside wallmounting device. Which principles should a nurse use to complete this task safely? 1. Principles of geometry and mathematics 2. Principles of ergonomics and geometry 3. Principles of sterile technique and mathematics 4. Principles of infection control and ergonomics performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first? 1. Check the equipment. 2. Contact the physician to review the care plan. 3. Continue the assessment because no actions are indicated at this time. 4. Document the reading because it reflects that the treatment has been effective. A client received chemotherapy 24 hours ago. Which precautions are necessary when When caring for the client? 1. Wear sterile gloves. 2. Place incontinence pads in the regular trash container. 3. Wear personal protective equipment when handling blood, body fluids, and feces. 4. Provide a urinal or bedpan to decrease the likelihood of soiling linens. An 11-year-old child contracted severe acute respiratory syndrome (SARS) when traveling abroad with her parents. The nurse knows she must put on personal protective equipment to protect herself while providing care. Based on the mode of SARS transmission, which personal protective equipment should the nurse wear? 1. Gloves 2. Gown and gloves 3. Gown, gloves, and mask 4. Gown, gloves, mask, and eye goggles or eye shieldA physician orders chest physiotherapy for a client with pulmonary congestion. When should the nurse plan to perform chest physiotherapy? 1. After meals 2. Before meals 3. When the client has time 4. When the nurse has time A nurse is preparing to help a client with weakness in his right leg move from his bed to a chair. Where should the nurse place the chair? 1. Parallel to the bed on the right side 2. Perpendicular to the bed on the right side 3. Parallel to the bed on the left side 4. Parallel to the bed on either side A client is in the bathroom when a nurse enters to give him a prescribed medication. What should the nurse do? 1. Leave the medication at the client's bedside. 2. Tell the client to be sure to take the medication; then leave it at the bedside. 3. Return to the client's room a few minutes later and remain there until the client takes the medication. 4. Wait for the client to return to bed; then leave the medication at the bedside. During preoperative teaching for a client who will undergo subtotal thyroidectomy, the nurse should include which statement? 1. "The head of your bed must remain flat for 24 hours after surgery." 2. "You should avoid deep breathing and coughing after surgery." 3. "You won't be able to swallow for the first day or two." 4. "You must avoid hyperextending your neck after surgery." A parent of a 9-year-old-child scheduled to have surgery expresses concern about the potential for postoperative infection. A nurse provides the parent with information about the measures taken to maintain surgical asepsis. Typical surgical asepsis involves: 1. using sterile surgical scrubs. 2. preoperative cleansing of jewelry worn by the surgical team.3. applying bandages to cover any wounds surgical team members have. 4. performing a preoperative surgical scrub for at least 3 to 5 minutes. An elderly client is diagnosed with pulmonary tuberculosis. Upset and tearful, he asks the nurse how long he must be separated from his family. Which nursing diagnosis is most appropriate for this client? 1. Anxiety 2. Social isolation 3. Deficient knowledge (disease process and treatment regimen) 4. Impaired social interaction A nurse preceptor is observing a new graduate during care of a client in contact isolation. Which action by the new graduate indicates a need for further teaching about handling infectious materials? 1. The nurse wears gloves during each client contact. 2. The nurse washes her hands when entering and exiting the room. 3. The nurse disposes of articles contaminated with blood in the room's biohazard container. 4. The nurse uses alcohol gel to clean her hands after changing linen soiled with urine and feces. A physician calls the nurse for an update on his client who underwent abdominal surgery 5 hours ago. The physician asks the nurse for the total amount of drainage collected in the Hemovac since surgery. The nurse reports that according to documentation, no drainage has been recorded. When the nurse finishes on the telephone, she goes to assess the client. Which assessment finding explains the absence of drainage? 1. The client has been lying on his side for 2 hours with the drain positioned upward. 2. The client has a nasogastric (NG) tube in place that drained 400 ml. 3. The Hemovac drain isn't compressed; instead it's fully expanded. 4. There is a moderate amount of dry drainage on the outside of the dressing. A client with hyperthyroidism is about to receive radioactive iodine as an outpatient. What safety measures should the nurse teach the client to protect his family while he undergoes treatment? 1. Good hand washing 2. How to isolate himself in one room of the house3. Use of disposable eating utensils 4. Not worrying about precautions After having several Stokes-Adams attacks within 4 months, a client reluctantly agrees to implantation of a permanent pacemaker. Before discharge, the nurse reviews pacemaker care and safety guidelines with the client and his spouse. Which safety precaution is appropriate for a client who has a pacemaker? 1. Stay at least 2′ away from microwave ovens. 2. Never engage in activities that require vigorous arm and shoulder movement. 3. Avoid going through airport metal detectors. 4. Avoid undergoing magnetic resonance imaging (MRI). A client has a wound with a drain. When cleaning around the drain, the nurse should wipe in which direction? 1. Laterally, from the center to the opposite side 2. From top to bottom 3. In a circle around the drain, outward from the center 4. In a circle around the drain, from the outer border to the center Nurses teach infant care and safety classes to assist parents in appropriately preparing to take their neonates home. Which statement about automobile restraints for infants is correct? 1. An infant should ride in a front-facing car seat until he weighs 20 lb (9.1 kg) and is 1 year old. 2. An infant should ride in a rear-facing car seat until he weighs 25 lb (11.3 kg) or is 1 year old. 3. An infant should ride in a front-facing car seat until he weighs 30 lb (13.6 kg) or is 2 years old. 4. An infant should ride in a rear-facing car seat until he weighs 20 lb and is 1 year old. A client with bipolar disorder has been taking lithium carbonate (Lithonate), as prescribed, for the past 3 years. Family members have brought this client to the hospital. The client hasn't slept, bathed, or changed clothes for 4 days; has lost 10 lb (4.5 kg) in the past month; and woke the entire family at 4 a.m. with plans to fly them to Hawaii for a vacation. Based on this information, the nurse understands that: 1. the family isn't supportive of the client.2. the client has stopped taking his medication. 3. the client hasn't accepted his diagnosis of bipolar disorder. 4. the client's lithium level should be measured before he receives the next lithium dose. When preparing a client with acquired immunodeficiency syndrome (AIDS) for discharge to home, the nurse should be sure to include which instruction? 1. "Put on disposable gloves before bathing." 2. "Sterilize all plates and utensils in boiling water." 3. "Avoid sharing such articles as toothbrushes and razors." 4. "Avoid eating foods from serving dishes shared by other family members." As an adolescent is receiving care, he's inadvertently injured with a warm compress. The nurse completes an incident report, knowing the report's goal is to: 1. reprimand staff for their actions. 2. protect the nurse from a lawsuit. 3. place the blame on the adolescent. 4. record facts surrounding each incident. Nurses were identified by the Centers for Disease Control and Prevention (CDC) as the people most likely to care for clients infected after the intentional release of the smallpox virus. Based on CDC guidelines, which group should volunteer to receive the smallpox vaccine? 1. Nurses age 50 and older who work in the emergency departments of community hospitals. 2. Nurses who served in the military and are now working in public health settings. 3. Nurses born after 1971 who are employed as triage nurses in large medical center emergency departments. 4. Nurses vaccinated against smallpox as children who are now working in a pediatric unit. A nurse is teaching a client how to rotate insulin injection sites. What is the purpose of rotating injection sites? 1. To prevent bruising 2. To prevent medication leakage from tissue or muscle3. To prevent erratic drug distribution 4. To prevent formation of hard nodules After administering an I.M. injection, a nurse should: 1. recap the needle and discard it in any medical waste container. 2. recap the needle and discard it in a puncture-proof container. 3. discard the uncapped needle in a puncture-proof container. 4. break the needle and discard the needle and syringe in any medical waste container. A staff member says she's really busy and asks the charge nurse to double-check a dose of insulin she has drawn up. The nurse holds up a bottle of Lente insulin, but the charge nurse notices a bottle of Lantus insulin on the medication cart. This nurse has made multiple medication errors and the charge nurse is concerned that she isn't safe. What should the charge nurse do? 1. State that she can't check the dose unless she sees the nurse draw it up. 2. Ask the nurse which bottle of insulin she used to draw up the client's dose. 3. Ask to see the original order, then determine if the dose is correct. 4. Tell the nurse that she'd like to start at the beginning to be on the safe side. A 22-month-old infant is to have moderate sedation for an outpatient procedure. The nurse knows that: 1. the infant should respond to gentle tactile or verbal stimulation. 2. the infant's reflexes will be decreased or absent. 3. the infant will remember the procedure. 4. the infant will need a patient-controlled analgesia (PCA) pump during sedation. A client tells the nurse that she thinks her amniotic membranes broke 2 hours ago. The nurse's priority is to: 1. assess the fetal heart rate once every hour. 2. administer I.V. antibiotics as ordered. 3. assess vital signs, especially temperature, every 4 hours. 4. prepare for the physician to confirm membrane rupture.A client with status asthmaticus requires endotracheal intubation and mechanical ventilation. Twenty-four hours after intubation, the client is started on the insulin infusion protocol. The nurse must monitor the client's blood glucose levels hourly and watch for which early signs and symptoms associated with hypoglycemia? 1. Sweating, tremors, and tachycardia 2. Dry skin, bradycardia, and somnolence 3. Bradycardia, thirst, and anxiety 4. Polyuria, polydipsia, and polyphagia A nurse is caring for a neonate with a myelomeningocele. The priority nursing care of a neonate with a myelomeningocele is primarily directed toward: 1. ensuring adequate nutrition. 2. preventing infection. 3. promoting neural tube sac drainage. 4. conserving body heat. A client's attorney may file a lawsuit within which time frame? 1. Discovery rule 2. Statute of limitations 3. Grace period 4. Alternative dispute resolution A client recovering from a closed head injury is restless and agitated. He still has a central venous catheter in place for antibiotic therapy. The nurse doesn't want to sedate the client, but she needs to protect the catheter and other less-restrictive measures have failed. Which method of restraint is best for this client? 1. Soft wrist restraints applied to both wrists 2. Soft restraints applied to each extremity 3. A vest restraint 4. Mitt restraints applied to both hands A client with a history of stroke underwent a right hemicolectomy 3 days ago. The client is calling out, asking for pain medication. The nurse caring for the client is administering medications to her other clients when she hears him call out. Concerned that he is disturbing the other clients, she quickly administers his pain medication. A short time later, the nurse returns to the client's room and finds him difficult to arouse. The nurse suddenlyrealizes that she administered 25 ml of the liquid medication instead of the ordered 25 mg, which is contained in 5 ml. How could the nurse have prevented this error? 1. Have another nurse administer the medications to the other clients. 2. Tell the client she'd administer his pain medication when she was finished administering to the other clients. 3. Carefully review the order and medication label, then calculate the ordered dose. 4. Reposition the client, then return to administer the drug. A client with high blood pressure is receiving an antihypertensive drug. The nurse knows that antihypertensive drugs commonly cause fatigue and dizziness, especially on rising. When developing a client teaching plan to minimize orthostatic hypotension, which instruction should the nurse include? 1. "Avoid drinking alcohol and straining at stool, and eat a low-protein snack at night." 2. "Wear elastic stockings, change positions quickly, and hold onto a stationary object when rising." 3. "Flex your calf muscles, avoid alcohol, and change positions slowly." 4. "Rest between demanding activities, eat plenty of fruits and vegetables, and drink 6 to 8 cups of fluid daily." A nurse is transferring a client from the bed to a chair. Which action should the nurse take during this client transfer? 1. Position the head of the bed flat. 2. Help the client dangle his legs. 3. Stand behind the client. 4. Place the chair facing away from the bed. A client with gastroenteritis is admitted to an acute care facility and presents with severe dehydration and electrolyte imbalances. Diagnostic tests reveal the Norwalk virus as the cause of gastroenteritis. Based on this information, the nurse knows that: 1. the client requires an antiviral agent. 2. enteric precautions must be continued. 3. enteric precautions can be discontinued. 4. the client's infection may be caused by droplet transmission.A client is in isolation after receiving an internal radioactive implant to treat cancer. Two hours later, the nurse discovers the implant in the bed linens. What should the nurse do first? 1. Stay in the room and call for help. 2. Pick up the implant with long-handled forceps and place it in a lead-lined container. 3. Leave the room and notify the radiation therapy department immediately. 4. Put the implant back in place, using forceps and a shield for self-protection, and call for help. During a facility disaster drill, an "injured client" presents to the emergency department with complaints of dry mouth, inability to focus his vision, and double vision. A nurse notes that the client has an unsteady gait and appears to be very weak. The client states, "My arms and legs feel like they just can't move." A nurse suspects the client may be a victim of bioterrorism with: 1. botulism. 2. anthrax. 3. herpes. 4. Ebola. A 3-month-old infant with meningococcal meningitis has just been admitted to the pediatric unit. Which nursing intervention has the highest priority? 1. Instituting droplet precautions 2. Administering acetaminophen (Tylenol) 3. Obtaining history information from the parents 4. Orienting the parents to the pediatric unit A 15-year-old adolescent confides in the nurse that he has been contemplating suicide. He says he has developed a specific plan to carry it out and pleads with the nurse not to tell anyone. What is the nurse's best response? 1. "We can keep this between you and me, but promise me you won't try anything." 2. "I need to protect you. I will tell your physician, but we don't need to involve your parents. We want you to be safe." 3. "For your protection, I can't keep this secret. After I notify the physician, we will need to involve your family. We want you to be safe." 4. "I will need to notify the local authorities of your intentions."Standard precautions include which measure? 1. Wearing gloves when changing a dressing 2. Disposing of needles in a puncture-resistant container 3. Wearing eye protection during tracheal suctioning 4. All of the above To treat cervical cancer, a client has had an applicator of radioactive material placed in the vagina. Which observation by the nurse indicates a radiation hazard? 1. The client is maintained on strict bed rest. 2. The head of the bed is at a 30-degree angle. 3. The client receives a complete bed bath each morning. 4. The nurse checks the applicator's position every 4 hours. A client diagnosed with acquired immunodeficiency syndrome is admitted to the emergency department with a closed head injury after being found unconscious on the kitchen floor by her neighbor. Based on information from the client's neighbor, the staff suspects domestic abuse. The client has a restraining order against the husband. The husband repeatedly attempts to visit the client. Which nursing action ensures client safety? 1. Place the client in a reverse isolation room and post an isolation sign on the door restricting visitors. 2. Instruct the client that she should put on her call light if her husband enters her room. 3. Admit the client to the pediatric unit under an assumed name so that the husband can't find her. 4. Inform hospital security personnel of the restraining order and formulate an action plan with security that protects the client. A female client with human immunodeficiency virus (HIV) receives family-planning counseling. Which statement about safer sex practices for persons with HIV is accurate? 1. If the client and her sexual partners are HIV-positive, unprotected sex is permitted. 2. A latex condom with spermicide provides the best protection against HIV transmission during sexual intercourse. 3. Contraceptive methods, such as hormonal contraceptives, implants, and injections, are recommended to prevent HIV transmission. 4. The intrauterine device is recommended for a client with HIV.A client is being admitted to the hospital with abdominal pain, anemia, and bloody stools. He complains of feeling weak and dizzy. He has rectal pressure and needs to urinate and move his bowels. The nurse should help him: 1. to the bathroom. 2. to the bedside commode. 3. onto the bedpan. 4. to a standing position so he can urinate. A nurse is teaching accident prevention to the parents of a toddler. Which instruction is appropriate for the nurse to tell the parents? 1. The toddler should wear a helmet when roller blading. 2. Place locks on cabinets containing toxic substances. 3. Teach the toddler water safety. 4. Don't allow the toddler to use pillows when sleeping. A nurse is teaching the parents of a young child how to handle suspected poisoning. If the child ingests poison, the parents should first: 1. administer ipecac syrup. 2. call an ambulance. 3. call the poison control center. 4. punish the child for being bad. A nurse is evaluating a postoperative client for infection. Which sign or symptom is most indicative of infection? 1. The presence of an indwelling urinary catheter 2. Rectal temperature of 100° F (37.8° C) 3. Red, warm, tender incision 4. White blood cell (WBC) count of 8,000/μl Which action is the best precaution against transmission of infection? 1. Eye prophylaxis with antibiotics for a neon te whose mother has hepatitis B infection 2. Strict isolation for a neonate whose mother has cytomegalovirus (CMV) infection 3. Eye prophylaxis with antibiotics for a neonate whose mother hasgonorrhea infection 4. Strict isolation for a neonate whose mother has human immunodeficiency virus (HIV) A mother of a 5-year-old child who was admitted to the hospital has a Protection from Abuse order for the child against his father. A copy of the order is kept on the pediatric medical surgical unit where the child is being treated. The order prohibits the father from having any contact with the child. One night, the father approaches the nurse at the nurses' station, politely but insistently demanding to see his child, and refusing to leave until he does so. What should the nurse do first? 1. Firmly tell the father he must leave. 2. Notify the nursing coordinator on duty. 3. Notify the nurse-manager. 4. Notify hospital security or the local authorities. A client in the fourth stage of labor asks to use the bathroom for the first time since giving birth. The client has oxytocin (Pitocin) infusing. Which response by the nurse is best? 1. "You'll have to wait until the vaginal bleeding stops." 2. "You'll have to wait until the oxytocin is infused." 3. "You may use the bathroom with my assistance." 4. "You may get up to the bathroom whenever you need to." When a nurse removes an I.V. from an client with acquired immunodeficiency syndrome (AIDS), blood splashes into her eyes. What should the nurse do next? 1. Rinse her eyes with water, record the incident on the client's chart, and see Employee Health. 2. Wash her hands, complete an incident report, and see a physician as soon as possible. 3. Rinse her eyes with water, report the incident, and go to Employee Health. 4. Rinse her eyes, contact Employee Health and document their findings. A nurse is applying an ostomy appliance to the ileostomy of a client with ulcerative colitis. Which action is appropriate? 1. Cutting the faceplate opening no more than 2″ larger than the stoma2. Gently washing the area surrounding the stoma using a facecloth and mild soap 3. Scrubbing fecal material from the skin surrounding the stoma 4. Maintaining wrinkles in the faceplate so it doesn't irritate the skin A nurse is caring for a client with acquired immunodeficiency syndrome. To adhere to standard precautions, the nurse should: 1. maintain strict isolation. 2. keep the client in a private room, if possible. 3. wear gloves when providing mouth care. 4. wear a gown when delivering the client's food tray. A nursing assistant tells the nurse that a client with paraplegia has an area of skin breakdown on his left calf. When the nurse assesses the client, he is sitting on a cushion in a wheelchair and wearing specialty boots. The nurse notes a circular wound 2 cm × 2 cm × 0.25 cm on the posterior aspect of the calf. What most likely caused the client's skin breakdown? 1. Leg rest of the wheelchair 2. Absence of sensation in the lower extremities and immobility 3. Sitting in the wheelchair for long periods of time 4. Specialty boots A nurse is caring for a client returning from cardiac catheterization. The nurse helps transfer the client back to bed. Which transfer technique uses appropriate ergonomic principles? 1. The nurse lowers the bed for transfer. She raises the bed before leaving the room, making sure to place the call light within reach. 2. The nurse maintains a narrow base of support during transfer and encourages the client to hold onto her if he's frightened. 3. The nurse raises the bed for transfer, maintains a wide base of support during transfer, and lowers the bed before leaving the room. 4. The nurse explains the procedure to the client and grabs the client under the arms to pull him over to the bed. A nurse is completing discharge teaching for the client who has left-sided hemiparesis following a stroke. When investigating the client's home environment, the nurse should focus on which nursing diagnosis?1. Risk for injury 2. Ineffective coping 3. Noncompliance 4. Diarrhea To avoid injury while caring for a client, which principle is most important for a nurse to remember? 1. Bending and twisting while providing care may cause injury. 2. The center of gravity is located at the waist. 3. A client's level of consciousness and ability to cooperate aren't important factors during transfer. 4. Tightening the abdominal muscles and tucking the pelvis may strain the lower back. A toddler is receiving an infusion of total parenteral nutrition via a Broviac catheter. As the child plays, the I.V. tubing becomes disconnected from the catheter. What should the nurse do first? 1. Turn off the infusion pump. 2. Position the child on the side. 3. Clamp the catheter. 4. Flush the catheter with heparin. A client in the surgical intensive care unit has skeletal tongs in place to stabilize a cervical fracture. Protocol dictates that pin care should be performed each shift. When providing pin care for the client, which finding should the nurse report to the physician? 1. Crust around the pin insertion site 2. A small amount of yellow drainage at the left pin insertion site 3. A slight reddening of the skin surrounding the insertion site 4. Pain at the insertion site A newly hired nurse on unit orientation prepares to administer vitamin K (AquaMEPHYTON) to a neonate. The nurse draws up 1 mg of vitamin K and prepares to administer a subcutaneous injection in the left, lateral anterior thigh. Which action by the nurse preceptor is best? 1. Praise the nurse for accurately preparing to administer the injection. 2. Stop the nurse and have her reevaluate her injection techniques.3. Distract the neonate by talking to her in a calm voice. 4. Stop the nurse and instruct her to administer the vitamin K using the Z-track method. In which way does a nurse play a key role in error prevention? 1. Identifying incorrect dosages or potential interactions of ordered medications 2. Never questioning a physician's order because the physician is ultimately responsible for the client outcome 3. Notifying the Occupational Safety and Health Administration (OSHA) of workplace violations 4. Informing the client of the Patient's Bill of Rights A nurse is teaching a client about insulin infusion pump use. What intervention should the nurse include to prevent infection at the injection site? 1. Change the needle every 3 days. 2. Wear sterile gloves when inserting the needle. 3. Take the ordered antibiotics before initiating treatment. 4. Use clean technique when changing the needle. A child, age 5, takes amoxicillin (Amoxil) orally three times per day to treat otitis media. For the most accurate calculation of a safe dosage, the nurse should use: 1. the child's weight in kilograms. 2. Young's rule based on the child's age. 3. Clark's rule based on the child's weight in pounds. 4. the child's body surface area. A school-age child begins to have a seizure while walking to the bathroom. What should the nurse do first? 1. Call the physician caring for the child. 2. Ease the child to the floor and turn him on his side. 3. Administer diazepam (Valium) through the I.V. tubing. 4. Notify the parents so they can be with their child. A nurse inadvertently gives a client a double dose of an ordered medication. After discovering the error, whom should the nurse notify first?1. The client 2. The prescriber 3. The nurse's lawyer 4. The risk manager An elderly client with a diagnosis of chronic renal failure is being discharged to home with his wife. The home health nurse visits the hospital before discharge to discuss home safety with the client, who reports decreased mobility and a need for greater assistance with activities of daily living. The nurse focuses her home-safety teaching on: 1. having adequate lighting, removing cluttered paths, and using nonskid bathroom surfaces. 2. avoiding unsteady ladders, overloaded electrical outlets, and pesticides. 3. properly storing plastic bags and guns and replacing steps without handrails. 4. replacing defective smoke detectors, storing flammable liquids properly, and repairing steps with broken concrete. A nurse recognizes that a client with tuberculosis needs further teaching when the client states: 1. "I'll have to take these medications for 9 to 12 months." 2. "It won't be necessary for the people I work with to take medication." 3. "I'll need to have scheduled laboratory tests while I'm on the medication." 4. "The people I have contact with at work should be checked regularly." A nurse is preparing a client for cardiac catheterization. The nurse knows that she must provide which nursing intervention when the client returns to his room after the procedure? 1. Withhold analgesics for at least 6 hours after the procedure. 2. Assess the puncture site frequently for hematoma formation or bleeding. 3. Inform the client that he may experience numbness or pain in his leg. 4. Restrict fluids for 6 hours after the procedure. A child, age 5, with an intelligence quotient (IQ) of 65 is admitted to the facility for evaluation. When planning care, the nurse should keep in mind that this child: 1. is within the lower range of normal intelligence. 2. would have a diagnosis of mild mental retardation.3. would have a diagnosis of moderate mental retardation. 4. would have a diagnosis of severe mental retardation. The nurse is reviewing sterile procedures with a student nurse. The nurse understands that the student requires additional teaching when the student identifies which procedure as requiring sterile technique? 1. I.V. insertion 2. Nasogastric (NG) tube placement 3. Urinary catheterization 4. Wound care involving burns Which steps should a nurse follow to insert a straight urinary catheter? 1. Create a sterile field, drape the client, clean the meatus, and insert the catheter 6″. 2. Put on gloves, prepare equipment, create a sterile field, expose the urinary meatus, and insert the catheter 6″. 3. Prepare the client and equipment, create a sterile field, put on gloves, clean the urinary meatus, and insert the catheter until urine flows. 4. Prepare the client and equipment, create a sterile field, test the catheter balloon, clean the meatus, and insert the catheter until urine flows. When changing a sterile surgical dressing, a nurse first must: 1. wash her hands. 2. put on sterile gloves. 3. remove the old dressing while wearing clean gloves. 4. open sterile packages and moisten the dressings with sterile saline solution. A positive Mantoux test indicates that a client: 1. is actively immune to tuberculosis. 2. has produced an immune response. 3. will develop full-blown tuberculosis. 4. has an active case of tuberculosis. Which instruction should a nurse include in an injury-prevention plan for a pregnant client? 1. "Wear your seat belt across your tummy."2. "Position the steering wheel toward your abdomen." 3. "It's OK to start learning a new sport during your pregnancy." 4. "Take rest periods during the day." Which nursing action is essential when providing continuous enteral feeding? 1. Elevating the head of the bed 2. Positioning the client on his left side 3. Warming the formula before administering it 4. Adding methylene blue to the enteral feeding to detect aspiration A physician orders a stool culture to help diagnose a client with prolonged diarrhea. The nurse who obtains the stool specimen should: 1. take the specimen to the laboratory immediately. 2. apply a solution to the stool specimen. 3. collect the specimen in a sterile container. 4. store the specimen on ice. An emergency department nurse is awaiting the arrival of multiple persons exposed to botulism at the local shopping mall. What should the nurse do? 1. Notify community agencies of the incident. 2. Separate those exposed to botulism from those who weren't exposed. 3. Activate the facility's emergency disaster plan. 4. Implement contact precautions with all exposed victims. When a toddler with croup is admitted to the facility, a physician orders treatment with a mist tent. As the parent attempts to put the toddler in the crib, the toddler cries and clings to the parent. What should the nurse do to gain the child's cooperation with the treatment? 1. Turn off the mist so the noise doesn't frighten the toddler. 2. Let the toddler sit on the parent's lap next to the mist tent. 3. Encourage the parent to stand next to the crib and stay with the child. 4. Put the side rail down so the toddler can get into and out of the crib unaided. A client with Alzheimer's disease has a nursing diagnosis of Risk for injury related to memory loss, wandering, and disorientation. To prevent injury, which nursing intervention should appear in this client's care plan?1. Provide the client with detailed instructions. 2. Keep the client sedated whenever possible. 3. Remove potential hazards from the client's environment. 4. Use restraints at all times. At 39 weeks' gestation, a pregnant client is admitted to the labor and delivery area in active labor. During the admission interview, she reports that her membranes haven't ruptured. Her history reveals that this is her third pregnancy, she previously experienced a stillbirth at 38 weeks' gestation, and she has one child at home. Which of these findings indicates the need for electronic fetal monitoring (EFM)? 1. Third pregnancy 2. Intact membranes 3. 39 weeks' gestation 4. Previous stillbirth A nurse discovers scabies when assessing a client who has just been transferred to the medical-surgical unit from the day surgery unit. To prevent scabies infection in other clients, the nurse should: 1. wash her hands, apply a pediculicide to the client's scalp, and remove any observable mites. 2. isolate the client's bed linens until the client is no longer infectious. 3. notify the nurse in the day surgery unit of a potential scabies outbreak. 4. place the client on enteric precautions. An infant, age 3 months, undergoes surgical repair of a cleft lip. After surgery, the nurse should use which equipment to feed the infant? 1. Single-hole nipple 2. Plastic spoon 3. Paper straw 4. Rubber dropper A nurse prepares to transfer a client from a bed to a chair. Which principle demonstrates safe body mechanics? 1. The nurse stands an arm's length away from the client. 2. The nurse uses a rocking motion while helping the client to stand.3. The nurse keeps her knees straight and stiff and bends at the waist. 4. The nurse keeps her feet as close together as possible. A client is admitted to the acute psychiatric care unit after 2 weeks of increasingly erratic behavior. He has been sleeping poorly, has lost 8 lb (3.6 kg), is poorly groomed, exhibits hyperactivity, and loudly denies the need for hospitalization. Which nursing intervention takes priority for this client? 1. Providing adequate hygiene 2. Administering a sedative as ordered 3. Decreasing environmental stimulation 4. Involving the client in unit activities When leaving the room of a client in strict isolation, the nurse should remove which protective equipment first? 1. Cap 2. Mask 3. Gown 4. Gloves A nurse is caring for a client with delirium. The nurse's priority is to provide: 1. a safe environment. 2. an opportunity to release frustration. 3. ordered medications. 4. Medications as needed, judiciously. A physician has ordered a heating pad for an elderly client's lower back pain. Which item would be most important for a nurse to assess before applying the heating pad? 1. Client's risk for falls 2. Client's vital signs and breath sounds 3. Client's nutritional status 4. Client's level of consciousness A nurse is caring for a 16-year-old adolescent with a head injury resulting from a fight after a high school football game. A physician has intubated the client and written orders to wean him from sedation therapy. A nurse needs further assessment data to determine whether:1. she'll have to apply restraints to prevent the client from dislodging the endotracheal (ET) tube. 2. nutritional protocol will be effective after the client sedation therapy is tapered. 3. to continue I.V. administration of other scheduled medications. 4. payment status will change if the client isn't sedated. A pregnant client is diagnosed with group B streptococcus chorioamnionitis. The nurse should expect to administer which medication to prevent fetal transmission? 1. penicillin G potassium (Pfizerpen) I.V. to the client 2. amoxicillin (Amoxil) P.O. to the client 3. ceftriaxone (Rocephin) I.M. to the neonate immediately after delivery 4. methylprednisolone (Solu-Medrol) I.V. to the client A client with end-stage chronic obstructive pulmonary disease (COPD) requires bi-level positive airway pressure (BiPAP). While caring for the client, the nurse determines that bilateral wrist restraints are required to prevent compromised care. Which client care outcome is associated with restraint use in the client who requires BiPAP? 1. The client will remain infection-free. 2. The client will maintain adequate oxygenation. 3. The client will maintain adequate urine output. 4. The client will remain pain-free. While preparing to discharge a 9-month-old infant who's recovering from gastroenteritis and dehydration, the nurse teaches the parents about their infant's dietary and fluid requirements. The nurse should include which other topic in the teaching session? 1. Nursery schools 2. Toilet training 3. Safety guidelines 4. Preparation for surgery A client found sitting on the floor of the bathroom in the day treatment clinic has moderate lacerations on both wrists. Surrounded by broken glass, she sits staring blankly at the lacerations. What is the most important action for the nurse to take next to the client? 1. Enter the room quietly and move next to the client to assess her injuries. 2. Call for staff back-up before entering the room and restraining the client.3. Sit quietly next to her. 4. Approach the client slowly while speaking in a calm voice, calling her by her name, and telling her that the nurse is there to help her. A nurse is reviewing a client's prenatal history. Which finding indicates a genetic risk factor? 1. The client is 25 years old. 2. The client has a child with cystic fibrosis. 3. The client was exposed to rubella at 36 weeks' gestation. 4. The client has a history of preterm labor at 32 weeks' gestation. Which statement indicates that a client with diabetes mellitus understands proper foot care? 1. "I'll schedule an appointment with my physician if my feet start to ache." 2. "I'll rotate insulin injection sites from my left foot to my right foot." 3. "I'll go barefoot around the house to avoid pressure areas on my feet." 4. "I'll wear cotton socks with well-fitting shoes." A client who reports increasing difficulty swallowing, weight loss, and fatigue is diagnosed with esophageal cancer. Because this client has difficulty swallowing, the nurse should assign highest priority to: 1. helping the client cope with body image changes. 2. ensuring adequate nutrition. 3. maintaining a patent airway. 4. preventing injury. A preschooler goes into cardiac arrest. When performing cardiopulmonary resuscitation (CPR) on a child, how should the nurse deliver chest compressions? 1. With the fingers of one hand 2. With two fingertips 3. With the palm of one hand 4. With the heel of one hand A nurse applies an external electronic fetal monitor (EFM) to assess a client's uterine contractions and evaluate the fetal heart rate (FHR). However, the client is uncomfortable and changes positions frequently, making FHR hard to assess. Consequently, the physiciandecides to switch to an internal EFM. Before internal monitoring can begin, which event must occur? 1. The membranes must rupture. 2. The client must receive anesthesia. 3. The cervix must be fully dilated. 4. The fetus must be at 0 station. A nurse is preparing to perform complex abdominal wound care. Which action is most appropriate? 1. Keeping the side rails up 2. Positioning the overbed table away from the bed 3. Raising the bed to approximately waist level 4. Positioning the client on the far side of the bed Which of the following objects poses the most serious safety threat to a 2-year-old child in the hospital? 1. Crayons and paper 2. Stuffed teddy bear in the crib 3. Mobile hanging over the crib 4. Side rails in the halfway position During a bath, a neonate has a nursing diagnosis of Risk for injury related to slippage while bathing. Which intervention best addresses this nursing diagnosis? 1. Hold the neonate loosely and gently. 2. Support the neonate's head and back with the forearm. 3. Use one hand to support the neonate's head. 4. Strap the neonate into the bath basin. A client receives a sealed radiation implant to treat cervical cancer. When caring for this client, the nurse should: 1. consider the client's urine, feces, and vomitus to be highly radioactive. 2. consider the client to be radioactive for 10 days after implant removal. 3. allow soiled linens to remain in the room until after the client is discharged.4. maintain the client on complete bed rest with bathroom privileges only. A nurse is caring for a female client following a motor vehicle accident resulting in paraplegia. The client is ready for discharge to home with her husband, who states, "I'm scared to carry her because I'm afraid I'll either hurt my back or drop her." A nurse identifies a need for discharge teaching of the husband in regard to: 1. ergonomic principles and body mechanics. 2. the importance of monitoring urinary elimination. 3. nutritional changes for the client with paraplegia. 4. signs and symptoms of chronic back pain that he should report to his physician. A child, age 5, is to have potassium added to his I.V. fluid. Before initiating this therapy, the nurse first should: 1. assess the child's apical pulse rate. 2. measure the blood pressure. 3. monitor fluid intake and output. 4. assess respiratory rate and depth. A nurse is caring for a client with thrombocytopenia. What is the best way to protect this client? 1. Limit visits by family members. 2. Encourage the client to use a wheelchair. 3. Use the smallest needle possible for injections. 4. Maintain accurate fluid intake and output records. A nurse is providing injury-prevention education to the parents of a school-age child. The parents admit that they keep a gun in their home. Which of the nurse's statements is most appropriate? 1. "The gun should be kept in a discreet location out of your child's sight." 2. "Your child should attend a community gun-safety program." 3. "Remind your child that only a parent may touch the gun." 4. "The gun should be stored in a locked cabinet." A client begins to experience alcoholic hallucinosis. After administering medication, what is the best nursing intervention? 1. Keeping the client restrained in bed2. Checking the client's blood pressure every 15 minutes 3. Providing a quiet environment 4. Offering the client oral liquids every 30 minutes Which nursing intervention is most helpful for a client experiencing a panic attack? 1. Encouraging the client to identify what precipitated the attack 2. Promoting the client's interaction with others to reduce anxiety through diversion 3. Staying with the client and remaining calm, confident, and reassuring 4. Reducing intolerable stimuli by encouraging the client to stay in the room alone until his anxiety abates A nurse is deciding whether to report a suspected case of child abuse. Which criterion is the most important for the nurse to consider? 1. Inappropriate parental concern for the degree of injury 2. Absence of parents to question about the injury 3. Inappropriate response of the child to the injury 4. Incompatibility between the child's history and the injury When moving a client in bed, the nurse can ensure proper body mechanics by: 1. standing with her feet apart. 2. lifting the client to the proper position. 3. straightening her knees and back. 4. standing several feet from the client. A toddler is diagnosed with a dislocated right shoulder and a simple fracture of the right humerus. Which behavior suggests that the child's injuries stem from abuse? 1. Trying to sit up on the stretcher 2. Trying to move away from the nurse 3. Not answering the nurse's questions 4. Not crying when moved Which precautions should a nurse include in the care plan for a client with leukemia and neutropenia? 1. Have the client use a soft toothbrush and electric razor, avoid using enemas, andwatch for signs of bleeding. 2. Put on a mask, gown, and gloves when entering the client's room. 3. Provide a clear liquid, low-sodium diet. 4. Eliminate fresh fruits and vegetables, avoid using enemas, and practice frequent hand washing. For an infant who's about to undergo a lumbar puncture, the nurse should place the infant in: 1. an arched, side-lying position, with the neck flexed onto the chest. 2. an arched, side-lying position, avoiding flexion of the neck onto the chest. 3. a mummy restraint. 4. a prone position, with the head over the edge of the bed. A client is admitted to the facility with a productive cough, night sweats, and a fever. Which action is most important in the initial care plan? 1. Assessing the client's temperature every 8 hours 2. Placing the client in respiratory isolation 3. Monitoring the client's fluid intake and output 4. Wearing gloves during all client contact A client who speaks little English has emergency gallbladder surgery. During discharge preparation, which nursing action would best help this client understand wound care instructions? 1. Asking frequently whether the client understands the instructions 2. Asking an interpreter to relay the instructions to the client 3. Writing out the instructions and having a family member read them to the client 4. Demonstrating the procedure and having the client return the demonstration When planning care for a client who has ingested phencyclidine (PCP), the nurse's highest priority should be meeting the: 1. client's physical needs. 2. client's safety needs. 3. client's psychosocial needs.4. client's medical needs. When teaching parents about fifth disease (erythema infectiosum) and its transmission, the nurse should provide which information? 1. Fifth disease is transmitted by respiratory secretions. 2. Fifth disease has an unknown transmission mode. 3. Fifth disease is transmitted by respiratory secretions, stool, and urine. 4. Fifth disease is transmitted by stool. A client admitted to the psychiatric unit for treatment of a panic attack comes to the nurses' station in obvious distress. After finding the client short of breath, dizzy, trembling, and nauseated, a nurse should first: 1. ask the client why he is upset. 2. administer an antianxiety medication, as ordered, and instruct the client to lie down in his room. 3. escort the client to a quiet area and suggest that he use a relaxation exercise he's been taught. 4. assure the client that his symptoms will disappear after he lies down and relaxes. Mental health laws in each state specify when restraints may be used and which type of restraints may be used. Most laws stipulate that restraints may be used: 1. for a maximum of 2 hours. 2. as necessary to control the client. 3. if a client poses a present danger to himself or others. 4. only with the client's consent. A nurse performing an assessment determines that a client with anorexia nervosa is currently unemployed and has a family history of affective disorders, obesity, and infertility. Based on this information, the nurse should monitor the client for which health concern? 1. Alcohol abuse 2. Avoidance behavior 3. Suicide potential 4. Explosive outbursts A nurse is performing discharge teaching for an elderly client diagnosed with osteoporosis. Which statement about home safety should the nurse include?1. "Most falls among the elderly occur outside the home. Clients should confine themselves to their homes as much as practical." 2. "Most accidental injuries among the elderly are automobile-related. Elderly clients should have vision testing every 6 months while they're still driving." 3. "Because of the increase in home burglaries involving the elderly, these clients should have burglar bars on every window in the home." 4. "Most falls among the elderly occur in the home. These clients should remove throw rugs and install bathroom grab bars." Standard precautions were designed for the care of all hospitalized clients, regardless of their diagnosis or infection status. Guidelines for standard precautions include: 1. immediately recapping used needles. 2. disposing of sharp instruments in an impervious container. 3. wearing gloves only for sterile procedures. 4. substituting regular eyeglasses for eye protection. A client with acute bronchitis is admitted to the health care facility and is receiving supplemental oxygen via nasal cannula. When monitoring this client, the nurse suddenly hears a high-pitched whistling sound. What is the most likely cause of this sound? 1. The water level in the humidifier reservoir is too low. 2. The oxygen tubing is pinched. 3. The client has a nasal obstruction. 4. The oxygen concentration is above 44%. A nurse is teaching the mother of an infant about the importance of immunizations. The nurse should teach her that active immunity: 1. develops rapidly and is temporary. 2. occurs by antibody transmission. 3. results from exposure of an antigen through immunization or disease contact. 4. may be transferred by mother to neonate. Which action is the priority when assessing a suicidal client who has ingested a handful of unknown pills? 1. Determining if the client was trying to harm himself2. Determining if the client has a support system 3. Determining if the client's physical condition is life-threatening 4. Determining if the client has a history of suicide attempts A client is returned to his room after a subtotal thyroidectomy. Which piece of equipment is most important for the nurse to keep at the client's bedside? 1. Indwelling urinary catheter kit 2. Tracheostomy set 3. Cardiac monitor 4. Humidifier A nurse is providing care for a pregnant 16-year-old. The client says that she's concerned she may gain too much weight and wants to start dieting. The nurse should respond by saying: 1. "Now isn't a good time to begin dieting because you are eating for two." 2. "Let's explore your feelings further." 3. "Nutrition is important because depriving your baby of nutrients can cause developmental and growth problems." 4. "The prenatal vitamins should ensure the baby gets all the necessary nutrients." A client suffers acute respiratory distress syndrome as a consequence of shock. The client's condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm? 1. Kinking of the ventilator tubing 2. A disconnected ventilator tube 3. An ET cuff leak 4. A change in the oxygen concentration without resetting the oxygen level alarm What should a nurse do to ensure a safe hospital environment for a toddler? 1. Place the child in a youth bed. 2. Move stacking toys out of reach. 3. Pad the crib rails. 4. Move the equipment out of reach.A nurse is developing a teaching plan for a client diagnosed with osteoarthritis. To minimize injury to the osteoarthritic client, the nurse should instruct the client to: 1. install safety devices in the home. 2. wear worn, comfortable shoes. 3. get help when lifting objects. 4. wear protective devices when exercising. Which infection control equipment is necessary for the client diagnosed with Clostridium difficile diarrhea? 1. Gloves 2. Mask 3. Face shield 4. N-95 respirator When reporting to the outpatient cancer center for his first chemotherapy treatment, a client appears anxious and apprehensive. Which statement by the nurse may help allay the client's anxiety? 1. "You may have a seat right over here." 2. "We wear gowns and gloves to administer chemotherapy drugs because they're very dangerous." 3. "You look anxious, don't worry you will get used to this place." 4. "As a precaution, we wear gowns, goggles, and gloves to administer the medication." A child, age 3, who tests positive for the human immunodeficiency virus (HIV) is placed in foster care. The foster parents ask the nurse how to prevent HIV transmission to other family members. How should the nurse respond? 1. "Make sure the child uses disposable plates and utensils." 2. "Use isopropyl alcohol to clean surfaces contaminated with the child's blood or body fluids." 3. "Don't let the child share toys with other children." 4. "Wear gloves when you're likely to come into contact with the child's blood or body fluids." A nurse observes a 10-month-old infant chewing on the security alarm attached to his identification bracelet. The nurse should:1. remove the security device because it's a choking hazard. 2. instruct the infant to stop chewing on the device. 3. distract the infant with a more appropriate toy. 4. instruct the infant's parent regarding the safety hazard. A client is having a tonic-clonic seizure. What should the nurse do first? 1. Elevate the head of the bed. 2. Restrain the client's arms and legs. 3. Place a tongue blade in the client's mouth. 4. Take measures to prevent injury. A client with viral hepatitis A is being treated in an acute care facility. Because the client requires enteric precautions, the nurse should: 1. place the client in a private room. 2. wear a mask when handling the client's bedpan. 3. wash her hands after touching the client. 4. wear a gown when providing personal care for the client. Which support surface is best for a comatose client who has multiple stage III pressure ulcers over two bony prominences? 1. Static support surface 2. Alternating pressure surface 3. Low-air-loss surface 4. Air-fluidized surface A staff nurse on the oncology unit must teach the new unit assistant about infection control practices on the unit. The nurse should explain that which measure is most important for preventing the spread of infection? 1. Restricting the presence of fresh flowers and plants on the floor 2. Using sick time when not feeling well 3. Performing proper hand hygiene 4. Refraining from eating or drinking at the nurses' stationWhich nursing action is most appropriate when trying to defuse a client's impending violent behavior? 1. Helping the client identify and express feelings of anxiety and anger 2. Diverting attention by involving the client in a quiet activity 3. Leaving the client alone until he can talk about his feelings 4. Placing the client in seclusion A nurse is caring for an elderly bedridden adult. To prevent pressure ulcers, which intervention should the nurse include in the care plan? 1. Turn and reposition the client at least once every 8 hours. 2. Vigorously massage lotion over bony prominences. 3. Develop a written, individual turning schedule. 4. Slide the client, rather than lifting, when turning. A physician orders penicillin G, 300,000 units I.M., for an 18-month-old child. Where should the nurse administer this injection? 1. Deltoid muscle 2. Vastus lateralis muscle 3. Dorsogluteal muscle 4. Ventrogluteal muscle A mother of several young children calls the nurse when her school-age child comes down with chickenpox. The nurse provides instruction on communicability and home management of this disease. Which response by the mother indicates effective teaching? 1. "I should keep my child at home until the fever is gone." 2. "I should have my child soak in oatmeal baths twice daily." 3. "I should give my child aspirin every 4 hours until the fever is gone." 4. "I should start checking my other children for lesions in about 4 weeks." Which action demonstrates a safe response plan in the event of fire? 1. Use elevators to travel to the location of the fire. 2. Make sure all fire doors are open. 3. Implement the RACE plan.4. n't notify the fire department if the fire is small enough for the nurse to extinguish. To assess the effectiveness of cardiac compressions during adult cardiopulmonary resuscitation (CPR), a nurse should palpate which pulse site? 1. Radial 2. Apical 3. Carotid 4. Brachial Which nursing intervention is most important when restraining a violent client? 1. Reviewing facility policy regarding how long the client may be restrained 2. Preparing an as-needed dose of the client's psychotropic medication 3. Checking that the restraints have been applied correctly 4. Asking if the client needs to use the bathroom or is thirsty A client comes to the clinic for diagnostic allergy testing. The nurse understands that intradermal injections are used for such testing based on which principle? 1. Intradermal injection is less painful. 2. Intradermal drugs are easier to administer. 3. Intradermal drugs diffuse more rapidly. 4. Intradermal drugs diffuse more slowly. A nurse has just been trained in how to use and care for a new blood glucose monitor. Which nursing intervention demonstrates proper use of a blood glucose monitor? 1. Ungloving the hands when removing the test strip 2. Smearing the drop of blood onto the reagent pad 3. Calibrating the machine after installing a new battery 4. Starting the timer on the machine while gathering supplies A charge nurse observes two nurses using inappropriate technique when starting an I.V. on a child. The charge nurse should first: 1. ignore the situation. 2. talk with the nurses about proper technique and the risk of infection resulting from improper technique.3. talk with the nurse-manager about her observations. 4. talk with the child's parents about infection control. A nurse provides preoperative education to a client scheduled to undergo elective surgery. The nurse includes instructions about proper skin care. Which client statement indicates the need for further education? 1. "I should begin to use an antibacterial soap a few days before my surgical procedure." 2. "On the morning of the surgery, I can shave my surgical area at home to save time." 3. "On the morning of surgery, I won't use lotions or cosmetics." 4. "I'll shower before coming to the hospital on the day of the surgery." A 6-year-old child has tested positive for West Nile virus infection. The nurse suspects the child has the severe form of the disease when she recognizes which signs and symptoms? 1. Fever, rash, and malaise 2. Anorexia, nausea, and vomiting 3. Fever, muscle weakness, and change in mental status 4. Fever, lymphadenopathy, and rash A nurse obtains a fingerstick glucose level of 45 mg/dl on a client newly diagnosed with diabetes mellitus. The client is alert and oriented, and the client's skin is warm and dry. How should the nurse intervene? 1. Give the client 4 oz of milk and a graham cracker with peanut butter. 2. Obtain a serum glucose level. 3. Obtain a repeat fingerstick glucose level. 4. Notify the physician. A home care nurse is visiting a left-handed client who has an implantable cardioverterdefibrillator (ICD) implanted in his left chest. The client tells the nurse how excited he is because he's planning to go rifle hunting with his grandson. How should the nurse respond? 1. "Enjoy your time with your grandson." 2. "You can't shoot a rifle left-handed because the rifle's recoil will traumatize the ICD site." 3. "Being that close to a rifle might make your ICD fire."4. "You'll need to take an extra dose of your antiarrhythmic before you shoot." When preparing a client for electroconvulsive therapy (ECT), the nurse should make sure that: 1. the client sees family members immediately before the procedure. 2. the client is scheduled for a brain scan immediately after the procedure. 3. the client has undergone a thorough medical evaluation. 4. the client has been on nothing-by-mouth (NPO) status for no more than 2 hours before the procedure. A client with Alzheimer's disease is being treated for malnutrition and dehydration. The nurse decides to place him closer to the nurses' station because of his tendency to: 1. forget to eat. 2. not change his position often. 3. exhibit acquiescent behavior. 4. wander. A health care team is involved in caring for a client with advanced Alzheimer's disease. During a team conference, a newly hired nurse indicates that she has never cared for a client with advanced Alzheimer's disease. Which key point about the disease should the charge nurse include when teaching this nurse? 1. The nursing staff should rely on the family to assist with care because family members know the client best. 2. Alzheimer's disease affects memory so the client doesn't need an explanation before procedures are performed. 3. As long as the client receives the ordered medication, special care measures aren't necessary. 4. Clients with Alzheimer's disease are at high risk for injury because of their impaired memory and poor judgment. A nurse is preparing to give an average-size 9-year-old child a preoperative I.M. injection. Which size needle should the nurse use? 1. 20G, 1″ 2. 20G, 1½″ 3. 22G, 1″4. 22G, 1½″ Which statement by a student nurse demonstrates that further instruction about cytotoxic drugs is needed? 1. "Cytotoxic parenteral infusion containers should be marked with special hazard labels." 2. "Infusion set administration connections should be tight." 3. "Nurses who are pregnant must wear gloves during administration of cytotoxic drugs." 4. "The infusion line should be primed into a gauze square inside a sealable plastic bag." A nurse must restrain a client to ensure the safety of other clients. When using restraints, which principle is a priority? 1. Have three staff members present, one to restrain each side of the client's body and one for the head. 2. Tie restraints securely to the side rails. 3. Use an organized, efficient team approach to apply and secure the restraints. 4. Secure restraints to the bed with knots to prevent the client from escaping. A toddler with bacterial meningitis is admitted to the inpatient unit. Which infection control measure should the nurse be prepared to use? 1. Reverse isolation 2. Strict hand washing 3. Standard precautions 4. Respiratory isolation A client is placed in isolation. Client isolation techniques attempt to break the chain of infection by interfering with the: 1. agent. 2. susceptible host. 3. transmission mode. 4. portal of entry. To examine an infant's thyroid gland, the nurse should place the infant in which position?1. Prone 2. Sitting 3. Standing 4. Supine A 10-year-old child arrives in the emergency department with suspected inhalation anthrax. Which intervention should the nurse perform first? 1. The nurse and other members of the health care team should put on N-95 respirator masks. 2. After obtaining blood cultures, the nurse should insert an I.V. catheter and begin antibiotic and I.V. therapy as ordered. 3. The nurse should move the client to a negative-pressure isolation room. 4. The nurse should prepare to admit the client to a medical-surgical unit. A physician enters a computer order for a nurse to irrigate a client's nephrostomy tube every 4 hours to maintain patency. The nurse irrigates the tube using sterile technique. After irrigating the tube, the nurse decides that she can safely use the same irrigation set for her 8-hour shift if she covers the set with a paper, sterile drape. This action by the nurse is: 1. appropriate because the irrigation just checks for patency. 2. inappropriate because irrigation requires strict sterile technique. 3. appropriate because the irrigation set will be used only during an 8-hour period. 4. inappropriate because the sterile drape must be cloth, not paper. When administering an oral medication to an infant, the nurse should take which action to minimize the risk of aspiration? 1. Administering the oral medication as quickly as possible 2. Placing the medication in the infant's formula bottle 3. Keeping the infant upright with the nasal passages blocked 4. Using an oral syringe to place the medication beside the tongue When caring for a neonate, what is the most important step the nurse can take to prevent and control infection? 1. Assessing frequently for signs of infection 2. Using sterile technique for all caregiving3. Practicing meticulous hand washing 4. Wearing gloves at all times A white male, age 43, with a tentative diagnosis of infective endocarditis is admitted to an acute care facility. His medical history reveals diabetes mellitus, hypertension, and pernicious anemia; he underwent an appendectomy 20 years earlier and an aortic valve replacement 2 years before this admission. Which history finding is a major risk factor for infective endocarditis? 1. Race 2. Age 3. History of diabetes mellitus 4. History of aortic valve replacement Which action should a nurse take when making a surgical bed? 1. Leave the bed in the high position when finished. 2. Place the pillow at the head of the bed. 3. Tuck the top sheet and blanket under the bottom of the bed. 4. Roll the client to the far side of the bed. After an upsetting divorce, a client who threatens to commit suicide with a handgun is involuntarily admitted to the psychiatric unit with major depression. Which nursing diagnosis takes highest priority for this client? 1. Hopelessness related to recent divorce 2. Ineffective coping related to inadequate stress management 3. Spiritual distress related to conflicting thoughts about suicide and sin 4. Risk for self-directed violence related to planning to commit suicide with a handgun A client with suspected severe acute respiratory syndrome (SARS) comes to the emergency department. Which physician order should the nurse implement first? 1. Institute isolation precautions. 2. Begin an I.V. infusion of dextrose 5% in half-normal saline solution at 100 ml/hour. 3. Obtain a nasopharyngeal specimen for reverse-transcription polymerase chainreaction testing. 4. Obtain a sputum specimen for enzyme immunoassay testing. A client with an infected abdominal wound must be placed in strict isolation for 10 days. What should the nurse do to help meet the client's emotional needs? 1. Tell the client that family members and significant others can't visit but may telephone at any time. 2. Gently explain that the client's movements must be limited while he's in the isolation room. 3. Describe why the client is in isolation and what will occur there, and reassure the client. 4. Tell the client to bring whatever personal items he wants into the isolation unit. A nurse is assessing a client for the risk of falls. The nurse should obtain: 1. gait and balance information. 2. the facility's restraint policy. 3. the family's psychosocial history. 4. the client's dietary preferences. A school nurse is evaluating a 7-year-old child who is having an asthma attack. The child is cyanotic and unable to speak, with decreased breath sounds and shallow respirations. Based on these physical findings, the nurse should first: 1. monitor the child with a pulse oximeter in her office. 2. prepare to ventilate the child. 3. return the child to class. 4. contact the child's parent or guardian. A client with suspected inhalation anthrax is admitted to the emergency department. Which action by the nurse takes the highest priority? 1. Monitor vital signs and oxygen saturation every 15 to 30 minutes. 2. Suction the client as needed to obtain a sputum specimen for culture and sensitivity. 3. Assess intake and output and maintain adequate hydration. 4. Reassure the client that intubation and mechanical ventilation will be temporary. A client who has started therapy for drug-resistant tuberculosis demonstrates understanding of tuberculosis transmission when he says:1. "My tuberculosis isn't contagious after I take the medication for 24 hours." 2. "I'm clear when my chest X-ray is negative." 3. "I'm contagious as long as I have night sweats." 4. "I'll stop being contagious when I have a negative acid-fast bacilli test." At night, an elderly client with senile dementia wanders into other clients' rooms, awakening them. What is the best nursing intervention for dealing with this client's insomnia and nocturnal roaming? 1. Administer a benzodiazepine at bedtime as ordered. 2. Administer a low-dose antipsychotic at bedtime as ordered. 3. Administer a barbiturate at bedtime as ordered. 4. Lock the client's door at bedtime. Before administering the evening dose of an ordered medication, a nurse on the evening shift finds an unlabeled, filled syringe in a client's medication drawer. What should the nurse do? 1. Discard the syringe to avoid a medication error. 2. Obtain a label for the syringe from the pharmacy. 3. Use the syringe because it looks like it contains the same medication the nurse was prepared to give the client. 4. Call the day nurse to verify the contents of the syringe. When preparing a client for a diagnostic study of the colon, the nurse teaches the client how to self-administer a prepackaged enema. Which statement by the client indicates effective teaching? 1. "I will administer the enema while sitting on the toilet." 2. "I will administer the enema while lying on my left side with my right knee flexed." 3. "I will administer the enema while lying on my right side with my left knee flexed." 4. "I will administer the enema while lying on my back with both knees flexed." During recovery from a stroke, a client is given nothing by mouth to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client's swallowing ability once per shift. This assessment evaluates: 1. cranial nerves I and II.2. cranial nerves III and V. 3. cranial nerves VI and VIII. 4. cranial nerves IX and X. While preparing to start a stat I.V. infusion, a nurse notices a broken ground on the infusion pump's plug. What should the nurse do first? 1. Use the pump as is because the physician has ordered the medication stat. 2. Obtain another pump from central supply to use for the infusion. 3. Tape the broken ground to the plug and use the pump. 4. Report the problem to the supervisor. Which nursing intervention is appropriate for a client with an arm restraint? 1. Applying the restraint loosely to prevent pressure on the skin 2. Tying the restraint to the side rail 3. Positioning the restrained arm in full extension 4. Monitoring circulatory status every 2 hours Several day-shift nurses complain that the night-shift nurses aren't performing the daily calibration of the capillary glucose monitoring apparatus, which is their responsibility. It would be most prudent for a nurse-manager to: 1. immediately remind the night-shift nurses of the daily calibrations. 2. arrange a meeting of the day-shift and night-shift nurses. 3. review the capillary glucose monitoring calibration log book. 4. counsel the night charge nurse about the discrepancy. A nurse is teaching a group of nursing assistants about infection-control measures. The nurse tells the group that the first line of intervention for preventing the spread of infection is: 1. wearing gloves. 2. administering antibiotics. 3. washing hands. 4. assigning clients to private rooms. What is the first action that a nurse should take after omitting an ordered medication?1. Notify the prescriber. 2. Document the omission and the reason for it. 3. Write an incident report. 4. Give the client an extra dose of the medication at the next scheduled administration time. A nurse is preparing to perform a postpartum assessment on a client who gave birth 5 hours ago. Which precaution should the nurse plan to take for this procedure? 1. Washing the hands 2. Washing the hands and wearing latex gloves 3. Washing the hands and wearing latex gloves and a barrier gown 4. Washing the hands and wearing latex gloves, a barrier gown, and protective eyewear A nurse is teaching high school students about transmission of the human immunodeficiency virus (HIV). Which comment by a student warrants clarification by the nurse? 1. "A man should wear a latex condom during intimate sexual contact." 2. "I've heard about people who got AIDS from blood transfusions." 3. "I won't donate blood because I don't want to get AIDS." 4. "I.V. drug users can get HIV from sharing needles." Before using a defibrillator to terminate ventricular fibrillation, a nurse should check the synchronizer switch. Why is this check so important? 1. The delivered shock must be synchronized with the client's QRS complex. 2. The defibrillator won't deliver a shock if the synchronizer switch is turned on. 3. The defibrillator won't deliver a shock if the synchronizer switch is turned off. 4. The shock must be synchronized with the client's T wave. A nurse is teaching childcare classes for adolescent mothers. To enhance the adolescents' understanding of infant safety in relation to the infant's perspective, the nurse should: 1. instruct the adolescents to discuss infant safety with their pediatricians. 2. present a video about pregnancy prevention.3. have the adolescents crawl around on the floor to look for potential hazards. 4. lecture the adolescents about poison control. A nurse is helping a client move up in the bed. Which action maintains good body mechanics? 1. Always keeping the bed in a low position 2. Having the client fold his arms across his chest 3. Raising the head of the bed 4. Having the client help himself as much as possible A newly admitted client tells a nurse that he is having suicidal thoughts every day. Which intervention should be the nurse's priority at this time? 1. A no-suicide contract 2. Weekly outpatient therapy 3. A second psychiatric opinion 4. One-to-one observation On admission to the psychiatric unit, a client with major depression reports that a family member is physically abusive and requests that the nurse not release any personal information to anyone. When the allegedly abusive family member calls the unit and demands information about the client's treatment, what is the nurse's best response? 1. "To protect clients' confidentiality, I can't give any information, including whether your relative is receiving treatment here." 2. "I can't give you any information. Goodbye." 3. "Your family member isn't accepting telephone calls." 4. "Your family member didn't sign an information release form with your name on it, so I can't give you any information." A client with stage II Alzheimer's disease is admitted to the short stay unit after cardiac catheterization that involved a femoral puncture. The client is reminded to keep his leg straight. A knee immobilizer is applied, but the client repeatedly attempts to remove it. The nurse is responsible for three other clients who underwent cardiac catheterization. What's the best step the nurse can take? 1. Continually remind the client not to move his leg and to leave the immobilizer alone. 2. Sedate the client.3. Apply wrist restraints. 4. Ask the staffing coordinator to assign a nursing assistant to sit with the client. A charge nurse is making arrangements for an elderly client newly admitted from the emergency department for treatment of suspected pyelonephritis. The charge nurse notes that the client has been assigned to a semiprivate room with another client who has the same last name. What should the nurse do first? 1. Make signs to alert staff members that both clients in the room have the same last name. 2. Ask the admissions department to assign the elderly client to a new room. 3. Ask the client if he'd be willing to answer to a different last name. 4. Verbally remind the staff to check each client's identification bracelet before administering medications. Which instruction should a nurse include in a home-safety teaching plan for a pregnant client? 1. Place a nonskid mat on the floor of the tub or shower. 2. It's OK to clean your cat's litter box. 3. It's OK to wear high heels. 4. Avoid having area rugs around your house. Which method is reliable for identifying a preschooler before administering a medication? 1. Check the name on the bed. 2. Check the hospital identification bracelet. 3. Ask the child his name. 4. Ask the parents at the bedside. A boy, age 3, develops a fever and rash and is diagnosed with rubella. His mother has just given birth to a baby girl. Which statement by the mother best indicates that she understands the implications of rubella? 1. "I told my husband to give my son aspirin for his fever." 2. "I'll ask the physician about giving the baby an immunization shot."3. "I don't have to worry because I've had the measles." 4. "I'll call my neighbor who's 2 months pregnant and tell her not to have contact with my son." A physician writes a medication order for meperidine (Demerol) 500 mg. The nurse's appropriate action would be to: 1. give the medication as ordered. 2. clarify the order with the pharmacy. 3. clarify the order with the physician. 4. clarify the order with another nurse on the unit. A client admitted with bacterial meningitis must be transported to the radiology department for a repeat computed tomography scan of the head. His level of consciousness is decreased, and he requires nasopharyngeal suctioning before transport. Which infection control measures are best when caring for this client? 1. Use standard precautions, which require gloves for suctioning. 2. Put on gloves, a mask, and eye protection. 3. Put on gloves, a mask, and eye protection during suctioning, and then apply a mask to the client's face for transport. 4. Take no special precautions for this client. Which condition could a mother have and still be encouraged to breast-feed her child? 1. Positive for human immunodeficiency virus (HIV) 2. Active tuberculosis (TB) 3. Endometritis 4. Cardiac disease A small child is admitted to the facility with a fever. Which statement made by the child's mother indicates understanding of the nurse's teaching? 1. "I will keep the child in light clothing." 2. "I will starve a fever and feed a cold." 3. "I should bring the child back to the emergency department (ED) if his temperature reaches 103° F (39.4° C)." 4. "If acetaminophen doesn't reduce the fever, I can give Motrin in 2 hours."A client refuses his evening dose of haloperidol (Haldol), then becomes extremely agitated in the day room while other clients are watching television. He begins cursing and throwing furniture. The nurse's first action is to: 1. check the client's medical record for an order for an as-needed dose of medication for agitation. 2. place the client in full leather restraints. 3. call the physician and report the behavior. 4. remove all other clients from the day room. The most appropriate site for a nurse to use to administer an I.M. injection to a 2-year-old child is the: 1. ventrogluteal muscle. 2. pectoral muscle. 3. femoral muscle. 4. deltoid muscle. A nurse-manager in the office of a group of surgeons has received complaints from discharged clients about inadequate instructions for performing home care. Knowing the importance of good, timely client education, the nurse-manager should take which steps? 1. Inform the nurses who work in the facility that client education should be implemented as soon as the client is admitted to either the hospital or the outpatient surgical center. 2. Review and revise the way client education is conducted in the surgeons' office. 3. Because none of the clients suffered any serious damage, the nurse-manager can safely ignore their complaints. 4. Work with the surgeons' staff and the nursing staff in the hospital and outpatient surgical center to evaluate current client education practices and make revisions as needed. The most effective way for a nurse to set limits for a newly admitted client who puts out cigarettes on the floor of the designated smoking room is to: 1. restrict the client's smoking to times when a staff member can supervise closely. 2. encourage other clients to speak with this client about dirtying the floor. 3. ask if the client puts out cigarettes on the floor at home. 4. hand the client an ashtray and state that he must use it or he won't beallowed to smoke. Which client is at highest risk for developing a hospital-acquired infection? 1. A client with a laceration to the left hand 2. A client who's taking prednisone (Deltasone) 3. A client with an indwelling urinary catheter 4. A client with Crohn's disease For a child with a Wilms' tumor, which preoperative nursing intervention takes highest priority? 1. Restricting oral intake 2. Monitoring acid-base balance 3. Avoiding abdominal palpation 4. Maintaining strict isolation A client asks a nurse a question about the Mantoux test for tuberculosis. The nurse should base her response on the fact that the: 1. area of redness is measured in 3 days and determines whether tuberculosis is present. 2. skin test doesn't differentiate between active and dormant tuberculosis infection. 3. presence of a wheal at the injection site in 2 days indicates active tuberculosis. 4. test stimulates a reddened response in some clients and requires a second test in 3 months. Policy and procedure require hand washing when caring for clients. Which statement about hand washing is true? 1. Frequent hand washing reduces transmission of pathogens from one client to another. 2. Wearing gloves is a substitute for hand washing. 3. Bar soap, which is generally available, should be used for hand washing. 4. Waterless products shouldn't be used in situations in which running water is unavailable. A client is preparing for discharge from the emergency department after sustaining an ankle sprain. The client is instructed to avoid weight bearing on the affected leg and is givencrutches. After instruction, the client demonstrates proper crutch use in the hallway. What additional information is most important to know before discharging the client? 1. Whether the client needs to navigate stairs routinely at home 2. Whether pets are present in the home 3. Whether the client parks his car on the street 4. Whether the client drives a car with a stick shift Which item in the care plan for a toddler with a seizure disorder should a nurse revise? 1. Padded side rails 2. Oxygen mask and bag system at bedside 3. Arm restraints while asleep 4. Cardiorespiratory monitoring A client with a walker is being discharged from the orthopedic unit to home. The nurse must teach the client how to use a walker properly. Which explanation demonstrates safe walker use? 1. Using the walker for support while rising from a chair 2. Adjusting the height of the walker so the arms aren't bent when the hands rest on the walker grips 3. Moving the walker, stepping with the affected leg, then stepping with the unaffected leg 4. Moving the walker, stepping with the unaffected leg, then stepping with the affected leg A nurse is teaching new staff members about groups considered at highest risk for suicide. Which group should the nurse emphasize? 1. Adolescents, men older than age 45, and persons who have made previous suicide attempts 2. Teachers, divorced persons, and substance abusers 3. Alcohol abusers, widows, and young married men 4. Depressed persons, physicians, and persons living in rural areas Which action must a nurse perform when cleaning the area around a Jackson-Pratt wound drain? 1. Clean from the center outward in a circular motion.2. Remove the drain before cleaning the skin. 3. Clean briskly around the site with alcohol. 4. Wear sterile gloves and a mask. A client with a diagnosis of bipolar disorder is energetic, impulsive, and verbalizes loudly in the community room. To prevent injury while complying with the principle of the leastrestrictive environment, which action should the nurse take to prevent escalation of the client's mood? 1. Place the client in seclusion with the door open. 2. Obtain a court mandate for a higher level of treatment. 3. Try to channel the client's energy into appropriate activities. 4. Monitor the client for escalation of manipulative behavior. A client has a soft wrist-safety device. Which assessment finding should the nurse investigate further? 1. A palpable radial pulse 2. A palpable ulnar pulse 3. Cool, pale fingers 4. Pink nail beds In the emergency department, a client with facial lacerations states that her husband beat her with a shoe. After her lacerations are repaired, the client waits to be seen by the crisis intake nurse, who will evaluate the continued threat of violence her husband represents. Suddenly the client's husband arrives, shouting that he wants to "finish the job." What is the first priority of the nurse who witnesses this scene? 1. Remaining with the client and staying calm 2. Calling a security guard and another staff member for assistance 3. Telling the client's husband that he must leave at once 4. Determining why the husband feels so angry An 8-year-old child is receiving moderate sedation for a medical procedure. The nurse is assessing the child's level of sedation. His gag reflex is intact, he's breathing comfortably on his own, and he opens his eyes on verbal request. The nurse recognizes that the child is: 1. undersedated. 2. appropriately sedated.3. deeply sedated. 4. oversedated. An elderly client has been admitted to the medical-surgical unit from the postanesthesia care unit. While the nurse is off the floor, the client falls out of bed and fractures his right leg and right wrist. The nurse finding him states, "The side rails were down and the bed was in the high position." The client's family files legal charges against the nurse and the hospital. Which charge most accurately reflects the nurse's actions? 1. Collective liability 2. Comparative negligence 3. Battery 4. Negligence A nurse is about to give a full-term neonate his first bath. How should the nurse proceed? 1. Bathe the neonate only after his vital signs have stabilized. 2. Clean the neonate with medicated soap. 3. Scrub the neonate's skin to remove the vernix caseosa. 4. Wash the neonate from feet to head. The fire alarm sounds on the maternal-neonatal unit at 0200. How can a nurse best care for her clients during a fire alarm? 1. Permit the mothers and their neonates to continue sleeping. 2. Immediately evacuate the unit. 3. Close all of the doors on the unit. 4. Do nothing because it's most likely a fire drill. While examining a client's leg, a nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressing should the nurse apply? 1. Dry sterile dressing 2. Sterile petroleum gauze 3. Moist sterile saline gauze 4. Povidone-iodine–soaked gauzeAfter a traumatic back injury, a client requires skeletal traction. Which intervention takes priority? 1. Monitoring the client for skin breakdown 2. Maintaining traction continuously to ensure its effectiveness 3. Supporting the traction weights with a chair or table to prevent accidental slippage 4. Restricting the client's fluid and fiber intake to reduce the movement required for bedpan use A nurse is preparing to administer a blood transfusion. Which action should the nurse take first? 1. Arrange for typing and crossmatching of the client's blood. 2. Compare the client's identification wristband with the tag on the unit of blood. 3. Start an I.V. infusion of normal saline solution. 4. Measure the client's vital signs. Before a routine checkup, an 8-month-old infant sits contentedly on the mother's lap, chewing on a toy. When preparing to examine this infant, what should the nurse plan to do first? 1. Measure the head circumference. 2. Auscultate the heart and lungs. 3. Elicit the pupillary reaction. 4. Weigh the child. A nurse is caring for a client who transferred from a local nursing home and who has tested positive for methicillin-resistant Staphylococcus aureus (MRSA). To prevent the spread of MRSA, the nurse knows she must: 1. maintain sterile technique at all times. 2. wear a mask when caring for the client. 3. give the client an I.V. dose of antibiotics. 4. keep a mask on the client. A nurse is preparing a client for a computed tomography (CT) scan that requires infusion of radiopaque dye. Which question is the most important for the nurse to ask?1. "When did you last have something to eat or drink?" 2. "When did you last take any medication?" 3. "Are you allergic to seafood or iodine?" 4. "How much do you weigh?" A nurse should determine a child's body surface area by using: 1. weight. 2. height. 3. a nomogram. 4. the difference between weight and height. A nurse is administering a purified protein derivative (PPD) test to a client. Which statement concerning PPD testing is true? 1. A positive reaction indicates that the client has active tuberculosis (TB). 2. A positive reaction indicates that the client has been exposed to the disease. 3. A negative reaction always excludes the diagnosis of TB. 4. The PPD can be read within 12 hours after the injection. A registered nurse (RN) and licensed practical nurse (LPN) are administering medications on the neurologic floor. The LPN prepares to administer phenytoin (Dilantin) to a client with a history of seizures. As the LPN walks into the room, she hands the medication to a nursing assistant. The LPN asks the nursing assistant to give the client the medication after completing the client's morning care. What should the registered nurse do? 1. Remind the LPN that she must administer the medications herself. 2. Do nothing because the client has been taking the medication for a long time. 3. Allow the nursing assistant to administer this dose and tell the LPN later that it's her responsibility to administer the medication. 4. Take the medication from the nursing assistant and administer it. How should a nurse position a 4-month-old infant when administering an oral medication? 1. Seated in a high chair 2. Restrained flat in the crib 3. Held on the nurse's lap4. Held in the bottle-feeding position A pregnant client asks the nurse about the percentage of congenital anomalies caused by drug exposure. How should the nurse respond? 1. 1% 2. 10% 3. 20% 4. 60% A client is diagnosed with shigellosis. The nurse teaches the client and family how the disease is transmitted and treated and discusses the need for enteric precautions. The nurse should explain that enteric precautions must be maintained: 1. during the acute disease stage and up to 48 hours after diarrhea stops. 2. during the acute disease stage and as long as the virus is shed (up to 30 days). 3. for 24 to 48 hours after anti-infective therapy begins. 4. until three fecal cultures are negative for Shigella. A nurse is teaching parents how to reduce the spread of impetigo. The nurse should encourage parents to: 1. teach children to cover mouths and noses when they sneeze. 2. have their children immunized against impetigo. 3. teach children the importance of proper hand washing. 4. isolate the child with impetigo from other members of the family. A nurse is caring for an elderly adult client admitted to the hospital from a nursing home because of a change in behavior. The client has a diagnosis of Alzheimer's disease and has started to experience episodes of incontinence. The hospital staff is having difficulty with toileting because the client wanders around the unit all day. To assist with elimination, a nurse should: 1. incorporate the client's toileting schedule into the pattern of his wandering. 2. ask the physician to order sedation to allow the client to rest. 3. ask the physician to order restraints to prevent wandering. 4. have the client wear two briefs at a time to ensure absorption of incontinent urine.A nurse is caring for a client with a fractured hip. The client is combative, confused, and trying to pull out necessary I.V. lines and an indwelling urinary catheter. The nurse should: 1. leave the client and get help. 2. obtain a physician's order to restrain the client. 3. read the facility's policy on restraints. 4. order soft restraints from the storeroom. To follow standard precautions, the nurse should carry out which measure? 1. Recapping needles after use 2. Wearing a gown when bathing a client 3. Wearing gloves when administering I.M. medication 4. Wearing gloves for all client contact A nurse is caring for a client on mechanical ventilation who's restless and trying to remove the endotracheal (ET) tube. Which action should the nurse perform next? 1. Apply wrist restraints to the client. 2. Turn the lights on in the room so she can observe the client closely. 3. Assess the client for pain and medicate as appropriate. 4. Tell the client he needs to leave the ET tube alone or she'll have to restrain him. A nurse is caring for a cardiac client who requires various cardiac medications. When the nurse helps the client out of bed for breakfast, the client becomes dizzy and asks to lie down. The nurse helps the client lie down, puts up the side rails, and obtains the client's blood pressure, which is 84/50 mm Hg. It's time for the nurse to administer the client's medications: nitroglycerin, metoprolol (Lopressor), and furosemide (Lasix). Which action by the nurse is best? 1. Withhold the medications and notify the physician. 2. Administer the medications immediately. 3. Encourage the client to sit up and eat breakfast. 4. Administer the nitroglycerin and metoprolol and withhold the furosemide. A nurse is preparing a client for magnetic resonance imaging (MRI) to confirm or rule out a spinal cord lesion. During the MRI scan, which action would pose a threat to the client? 1. The client lies still. 2. The client asks questions.3. The client hears thumping sounds. 4. The client wears a watch and wedding band. A 16-year-old girl visits the clinic for the first time. She tells the nurse that she has been exposed to herpes. Initially, with primary genital or Type 2 herpes simplex, the nurse should expect the girl to have: 1. dysuria and urine retention. 2. perineal ulcers and erosions. 3. bilateral inguinal lymphadenopathy. 4. burning or tingling on vulva, perineum, or vagina. X-rays reveal a leg fracture in a client who was brought to the emergency department after falling on ice. After a cast is applied and allowed to dry, the nurse teaches the client how to use crutches. Which instruction should the nurse provide about climbing stairs? 1. "Place both crutches on the first step and swing both legs upward to this step." 2. "Place the unaffected leg on the first step, followed by the crutches and the injured leg, which should move together." 3. "Place the crutches and injured leg on the first step, followed by the unaffected leg." 4. "Place the injured leg and the crutch on the unaffected side on the first step; the unaffected leg and crutch on the injured side follow." A client who has just been diagnosed with hepatitis A asks, "How did I get this disease?" What is the nurse's best response? 1. "You could have gotten it by using I.V. drugs." 2. "You must have received an infected blood transfusion." 3. "You probably got it by engaging in unprotected sex." 4. "You may have eaten contaminated restaurant food." A new nurse is asked to start an I.V. on an antepartum client. The new nurse has performed the procedure only once and isn't familiar with the I.V. pumps used in this facility. The new nurse should: 1. ask another new nurse to assist her. 2. attempt the procedure without assistance. 3. review the unit's procedure manual. 4. tell the client that she isn't experienced enough to start the I.V.The staff of an outpatient clinic has formed a task force to develop new procedures for swift, safe evacuation of the unit. The new procedures haven't been reviewed, approved, or shared with all personnel. When a nurse-manager receives word of a bomb threat, the task force members push for evacuating the unit using the new procedures. Which action should the nurse-manager take? 1. Determine that the procedures currently in place must be followed and direct staff to follow them without question. 2. Tell staff members to use whatever procedures they feel are best. 3. Ask staff members to quickly meet among themselves and decide what procedures to follow. 4. Tell staff members to assemble in the staff lounge, where she will quickly gather opinions about evacuation procedures before deciding what to do. A nurse will use surgical asepsis for which procedure? 1. Hand washing 2. Nasogastric tube irrigation 3. I.V. catheter insertion 4. Colostomy irrigation A nurse is obtaining a sterile urine specimen from a client's indwelling urinary catheter. During the procedure, the nurse should: 1. aspirate urine from the tubing port, using a sterile syringe and needle. 2. disconnect the catheter from the tubing and collect urine. 3. open the drainage bag and pour out some urine. 4. wear sterile gloves when collecting urine. When placing an indwelling urinary catheter in a female client, the nurse should advance the catheter how far into the urethra? 1. ½″ (1 cm) 2. 2″ (5 cm) 3. 6″ (15 cm) 4. 8″ (20 cm) A client with a suspected brain tumor is scheduled for a computed tomography (CT) scan. What should the nurse do when preparing the client for this test?1. Immobilize the neck before the client is moved onto a stretcher. 2. Determine whether the client is allergic to iodine, contrast dyes, or shellfish. 3. Place a cap over the client's head. 4. Administer a sedative as ordered. When discharging a 5-month-old infant from the hospital, the nurse checks to see whether the parent's car restraint system for the infant is appropriate. Which restraint system would be safest? 1. A front-facing convertible car seat in the middle of the back seat 2. A rear-facing infant safety seat in the front passenger seat 3. A rear-facing infant safety seat in the middle of the back seat 4. A front-facing convertible car seat in the back seat next to the window A client arrives on the psychiatric unit exhibiting extreme excitement, disorientation, incoherent speech, agitation, frantic and aimless physical activity, and grandiose delusion. Which nursing diagnosis takes highest priority for this client at this time? 1. Ineffective coping 2. Hopelessness 3. Risk for injury 4. Disturbed personal identity A 10-year-old child presents to the emergency department with dehydration. A physician orders 1 L of normal saline solution be administered at a rate of 60 ml/hour. While preparing the infusion, a nurse notices that the I.V. pump's safety inspection sticker has expired. Which action should the nurse take next? 1. After starting the fluids, contact the maintenance department and request a pump inspection. 2. Hang the fluids without the pump, carefully calculating the drip rate by visual inspection. 3. Take the pump out of commission and locate a pump with a valid inspection sticker. 4. Begin the infusion of the fluids while looking for a pump with a valid inspection sticker.A facility has a system for transcribing medication orders to a Kardex as well as a computerized medication administration record (MAR). A physician writes the following order for a client: "Prednisone 5 mg P.O. daily for 3 days." The order is correctly transcribed on the Kardex. However, the nurse who transcribes the order onto the MAR neglects to place the 3-day limitation on the record. On the fourth day after the physician wrote the order, a nurse administers prednisone 5 mg P.O. A nurse identifies the error during a chart audit. The person most responsible for the error is the: 1. nurse who incorrectly transcribed the order on the MAR. 2. nurse who administered the erroneous dose. 3. pharmacist who filled the order and provided the erroneous dose. 4. facility because of its policy on transcription of medications. A group of nursing assistants hired for the medical-surgical floors are attending hospital orientation. Which topic should the educator cover when teaching the group about caring for clients with diabetes mellitus? 1. Obtaining, reporting, and documenting fingerstick glucose levels 2. Treating hypoglycemia 3. Teaching the client dietary changes necessary with diabetes mellitus 4. Assessing the client experiencing a hypoglycemic reaction Which human element should a nurse consider during assessment of home drug administration? 1. The client's ability to recover 2. The client's occupational hazards 3. The client's socioeconomic status 4. The client's cognitive abilities A nurse implements a health care facility's disaster plan. Which action should she perform first? 1. Turn off all cellular phones and pagers. 2. Instruct all essential off-duty personnel to report to the facility within 24 hours. 3. Identify a command center at which activities are coordinated. 4. Provide treatment for incoming clients according to time of admission.An adolescent client with ruptured membranes is admitted to the hospital. A few hours after her arrival to the labor and delivery unit, the client's high school principal calls to inquire about her condition. How should the nurse respond? 1. "She most likely won't deliver for another 15 hours." 2. "She hasn't delivered her baby yet." 3. "I'll call you when she delivers." 4. "For confidentiality reasons, I can't give you any information." A nurse caring for a client who has just received chemotherapy infusion is wearing a disposable gown, gloves, and goggles for protection. The nurse knows that accidental exposure to chemotherapy agents can occur through: 1. inhalation of aerosols. 2. absorption through the gown. 3. absorption through the gloves. 4. absorption through the goggles. A nurse is caring for a client with a history of falls. The nurse's first priority when caring for a client at risk for falls is: 1. placing the call light for easy access. 2. keeping the bed in the lowest possible position. 3. instructing the client not to get out of bed without assistance. 4. keeping the bedpan available so that the client doesn't have to get out of bed. A nurse should question an order for a heating pad for a client who has: 1. active bleeding. 2. a reddened abscess. 3. an edematous lower leg. 4. purulent wound drainage. A nurse discussing injury prevention with a group of workers at a day-care center is focusing on toddlers. When discussing this age-group, the nurse should stress that: 1. accidents are the leading cause of death among toddlers. 2. the risk for homicide is highest among toddlers. 3. toddlers can distinguish right from wrong.4. toddlers will always chase a ball that rolls into the street. A client is scheduled for an EEG after having a seizure for the first time. Client preparation for this test should include which instruction? 1. "Don't eat anything for 12 hours before the test." 2. "Don't shampoo your hair for 24 hours before the test." 3. "Avoid stimulants and alcohol for 24 to 48 hours before the test." 4. "Avoid thinking about personal matters for 12 hours before the test." A nurse is working on the labor and delivery unit, a locked unit. The nurse understands that the purpose of security and video surveillance is to: 1. keep solicitors out of the unit. 2. keep family members from disturbing women in labor. 3. ensure the security of the neonates. 4. ensure that the health care team won't be disturbed. Which safeguard should a nurse employ with I.V. fluid administration for an infant? 1. Administration of fluid at the slowest possible rate 2. Use of a gravity infusion set 3. Use of a small I.V. infusion set 4. Use of an infusion pump to regulate the flow rate A client is admitted to the health care facility with active tuberculosis (TB). The nurse should include which intervention in the care plan? 1. Putting on an individually fitted mask when entering the client's room 2. Instructing the client to wear a mask at all times 3. Wearing a gown and gloves when providing direct care 4. Keeping the door to the client's room open to observe the client A client who's dehydrated has urinary incontinence and excoriation in the perineal area. Which action would be a priority? 1. Keeping the perineal area clean and dry 2. Offering the client the urinal every 3 hours3. Maintaining a fluid intake of 1 L/day 4. Applying moist, warm compresses to the client's groin If an infant's I.V. access site is in an extremity, the nurse should: 1. use a padded board to secure the extremity. 2. restrain all four extremities. 3. restrain the extremity to the bed's side rail. 4. allow the extremity to be loose. Which nursing instructions help parents of a child with hemophilia provide a safe home environment for their child? 1. "Pad the corners of coffee tables when your child is a toddler and provide kneepads for sports when the child is older." 2. "Establish a written emergency plan including what to do in specific situations and the names and phone numbers of emergency contacts." 3. "Be a role model to your child by wearing a helmet when riding a bike so your child will, too." 4. "Talk with your child about home safety and have him problem-solve hypothetical situations about his health." A 2-year-old child is admitted to the pediatric unit with fever, seizures, and vomiting. He's awake and alert. As the nurse is putting a gown on the child, the nurse notices petechiae across the child's chest, abdomen, and back. The nurse should: 1. question the mother about the child's allergies. 2. initiate standard precautions. 3. evaluate the child's neurologic status. 4. examine the child's throat and ears. A nurse is caring for a client who is at high risk for developing pneumonia. Which intervention should the nurse include on the client's care plan? 1. Keeping the head of the bed at 15 degrees or less 2. Turning the client every 4 hours to prevent fatigue 3. Using strict hand hygiene 4. Providing oral hygiene dailyA nurse is caring for a client diagnosed with a chlamydia infection. The nurse teaches the client about disease transmission and advises the client to inform his sexual partners of the infection. The client refuses, stating, "This is my business and I'm not telling anyone. Beside, chlamydia doesn't cause any harm like the other STDs." How should the nurse proceed? 1. Educate the client about why it's important to inform sexual contacts so they can receive treatment. 2. Inform the health department that this client contracted an STD. 3. Inform the client's sexual contacts of their possible exposure to chlamydia. 4. Do nothing because the client's sexual habits place him at risk for contracting other STDs. A client experiences orthostatic hypotension while receiving furosemide (Lasix) to treat hypertension. How should the nurse intervene? 1. Administer I.V. fluids as ordered. 2. Administer a vasodilator as ordered. 3. Insert an indwelling urinary catheter as ordered. 4. Instruct the client to sit for several minutes before standing. A night-shift nurse receives a call from the emergency department about a client with herpes zoster who is going to be admitted to the floor. Based on this diagnosis, where should the nurse assign the client? 1. Semi-private room with a client diagnosed with pneumonia 2. Semi-private room with a client who had chickenpox and was admitted with a GI bleed 3. Private room 4. Isolation room with negative airflow A client's membranes rupture during the 36th week of pregnancy. Eighteen hours later, the nurse measures the client's temperature at 101.8° F (38.8° C). After initiating ordered antibiotic therapy, the nurse should prepare the client for: 1. amniocentesis. 2. delivery. 3. sonography. 4. tocolytic therapy.A nurse is performing a sterile dressing change. Which action contaminates the sterile field? 1. Holding sterile objects above the waist 2. Pouring solution onto a sterile field cloth 3. Leaving a 1″ (2.5-cm) edge around the sterile field 4. Opening the outermost flap of a sterile package away from the body In a toddler, which injury is most likely the result of child abuse? 1. A hematoma on the occipital region of the head 2. A 1-inch forehead laceration 3. Several small, dime-sized circular burns on the child's back 4. A small isolated bruise on the right lower extremity As a client is being released from restraints, he says, "I'll never get that angry and lose it again. Those restraints were the worst things that ever happened to me." Which response by the nurse is most appropriate? 1. "Do you really mean what you just said?" 2. "I'd like to talk with you about your experience." 3. "That was the worst thing that ever happened to you?" 4. "Someday this experience won't bother you like it does now." A client who had abdominal surgery 4 days ago reports that "something gave way" when he sneezed. The nurse observes a wound evisceration. Which nursing action is the first priority? 1. Applying a sterile, moist dressing 2. Monitoring vital signs 3. Inserting a nasogastric (NG) tube 4. Putting the client on nothing-by-mouth (NPO) status The development of disaster plans should take into consideration that children are more susceptible to the effects of a chemical attack than adults because children: 1. have smaller body surface areas than adults. 2. breathe at a slower rate than adults. 3. have thinner skin than adults.4. have a low risk of developing rapid dehydration. A client who was bitten by a wild animal is admitted to an acute care facility for treatment of rabies. Which type of isolation does this client require? 1. Strict 2. Contact 3. Respiratory 4. Enteric If a manual end-of-shift count of controlled substances isn't correct, the nurse's best action is to: 1. investigate and correct the discrepancy, if possible, before proceeding. 2. immediately report the discrepancy to the nurse-manager, nursing supervisor, and pharmacy. 3. document the discrepancy on an incident report. 4. document the discrepancy on a opioid-inventory form. When implementing the planned care of a client with pneumonia, a nurse achieves proper placement of a tympanic thermometer probe in an adult's ear canal by: 1. pulling the ear pinna back, up, and out. 2. pulling the ear pinna back, down, and out. 3. pulling the ear pinna out. 4. pulling the ear pinna down. A client with a history of chronic hyperparathyroidism admits to being noncompliant. Based on initial assessment findings, the nurse formulates the nursing diagnosis of Risk for injury. To complete the nursing diagnosis statement for this client, which "related-to" phrase should the nurse add? 1. Related to bone demineralization resulting in pathologic fractures 2. Related to exhaustion secondary to an accelerated metabolic rate 3. Related to edema and dry skin secondary to fluid infiltration into the interstitial spaces 4. Related to tetany secondary to a decreased serum calcium level A nurse works in the neonatal intensive care unit. Her responsibility for disaster planning includes:1. developing the plan for disaster response and conducting weekly practice drills. 2. following the disaster coordinator's instructions if a disaster occurs. 3. ensuring the safety of all neonates in the disaster area. 4. collaborating in development and implementation of the plan. A client is scheduled for amniocentesis. When preparing her for the procedure, the nurse should: 1. ask the client to void. 2. instruct the client to drink 1 L of fluid. 3. prepare the client for I.V. anesthesia. 4. place the client on her left side. Which step must be done first when administering a blood transfusion? 1. Verify the blood product and client identity. 2. Verify the physician's order. 3. Verify client identity and blood product with another nurse. 4. Assess the I.V. site. A client is discharged to home following hospitalization for percutaneous endoscopic gastrostomy tube placement to assist with nutrition. His primary diagnosis is amyotrophic lateral sclerosis (ALS). He can transfer from the bed to a chair but can't walk. The client and his family are concerned about his ability to maintain his mobility at the highest possible level following a surgical procedure. The nursing diagnosis most appropriate for this client is: 1. Impaired physical mobility related to decreased motor agility secondary to ALS as manifested by inability to ambulate. 2. Caregiver role strain related to care recipient's unrealistic expectations of caregiver. 3. Impaired memory related to reduced quality and quantity of information processed. 4. Hopelessness related to impaired ability to cope. A client with a cerebellar brain tumor is admitted to an acute care facility. The nurse formulates a nursing diagnosis of Risk for injury. Which "related-to" phrase should the nurse add to complete the nursing diagnosis statement? 1. Related to visual field deficits 2. Related to difficulty swallowing3. Related to impaired balance 4. Related to psychomotor seizures Lower back pain is a common complaint among pregnant clients. Which comfort measure should a nurse include in her teaching plan for a pregnant client? 1. Wear high-heeled shoes. 2. Use an ergonomically correct desk chair. 3. Avoid tilting the pelvis forward. 4. Bend at the waist, not at the knees. In developing a security plan for a pediatric unit, a nurse must consider which factors? Select all that apply. 1. Identification of neonates, infants, toddlers, children, and adolescents at all times 2. The facility's physical layout 3. The climate in which the hospital is located 4. Available resources to obtain and maintain the security plan 5. Methods for educating all staff regarding the security plan When feeding a neonate with a cleft lip, the nurse should expect to: 1. administer I.V. fluids. 2. use a bulb syringe with a rubber tip. 3. provide thickened formula. 4. perform gastric gavage. Which nursing diagnosis takes highest priority for a client with a compound fracture? 1. Imbalanced nutrition: Less than body requirements related to immobility 2. Impaired physical mobility related to trauma 3. Risk for infection related to effects of trauma 4. Activity intolerance related to weight-bearing limitations A nurse is caring for a client with a central venous catheter. Which assessment finding would indicate possible systemic infection? 1. Low temperature2. Bradypnea 3. Tachypnea 4. Bradycardia A nurse notices that a client admitted for treatment of major depression is pacing, agitated, and becoming verbally aggressive toward other clients. What is the immediate care priority? 1. Ensuring the safety of this client and other clients on the unit 2. Offering the client a less-stimulating area in which to calm down 3. Removing the other clients from the area until this client settles down 4. Isolating the agitated client and offering sedation to calm his behavior A visiting nurse is teaching a client with heart failure about taking his medications. The client requires six different medications that are taken at four different times per day. The client is confused about when to take each medication. How should the nurse intervene? 1. Ask the client's family to take turns coming to the house at each administration time to assist the client with his medications. 2. Teach a family member to fill a medication compliance aid once per week so the client can independently take his medications. 3. Ask the physician if the client can take fewer pills each day. 4. Come to the client's house each morning to prepare the daily allotment of medications. A 3-year-old child is admitted to the hospital with an acute exacerbation of asthma. The child's history reveals that the child was exposed to chickenpox 1 week ago. When would this child require isolation? 1. Isolation isn't required. 2. Immediate isolation is required. 3. Isolation is required 10 days after exposure. 4. Isolation is required 12 days after exposure. To prevent oral complications when using a metered-dose inhaler, a nurse should instruct the client to: 1. keep the head of the bed at a 30-degree angle. 2. use the inhaler before meals. 3. rinse out his mouth after using the inhaler4. use the inhaler as needed. A nurse is caring for an older client who has had a hemorrhagic stroke. The client has exhibited impulsive behavior and, despite reminders from the nurse, doesn't recognize his limitations. Which priority measure should the nurse implement to prevent injury? 1. Encourage the client to do as much as possible without assistance, and to use the call light only in emergencies. 2. Install a bed alarm to remind the client to ask for assistance and to alert staff that the client is getting out of bed. 3. Encourage the family to reprimand the client if he doesn't ask for help with transfers and mobility. 4. Ask a physician to order a vest and wrist restraints. Just after delivery, a nurse measures a neonate's axillary temperature at 94.1° F (34.5° C). What should the nurse do? 1. Rewarm the neonate gradually. 2. Rewarm the neonate rapidly. 3. Observe the neonate hourly. 4. Notify the physician when the neonate's temperature is normal. A nurse is talking with a delusional client when the fire alarm sounds and a staff member closes the door to the client's room. The client becomes very agitated and declares, "The aliens have arrived!" Which actions are appropriate for the nurse to take? Select all that apply. 1. Leaving the room but telling the client she'll return soon 2. Telling the client that there's no danger and that everything's fine 3. Telling the client that the alarm is just a drill and that he shouldn't be afraid 4. Staying with the client until she receives further instructions 5. Continuing to speak to the client in a reassuring tone A registered nurse (RN) has been paired with a licensed practical nurse (LPN) for the shift. Whose care should the RN delegate to the LPN? 1. A 2-year-old child who nearly drowned 2 days earlier 2. A 19-month-old infant who had surgery for a fractured tibia 12 hours ago 3. A 6-month-old infant who has gastroenteritis and vomits every 30 minutes4. A 17-month-old infant who lost consciousness 2 hours earlier because of a head injury A nurse is preparing to administer a unit of blood to a client with anemia. After its removal from the refrigerator, the blood should be administered within: 1. 1 hour. 2. 2 hours. 3. 4 hours. 4. 6 hours. A home care nurse visits a client diagnosed with atrial fibrillation who is ordered warfarin (Coumadin). The nurse teaches the client about warfarin therapy. Which statement by the client indicates the need for further teaching? 1. "I'll watch my gums for bleeding when I brush my teeth." 2. "I'll use an electric razor to shave." 3. "I'll eat four servings of fresh, dark green vegetables every day." 4. "I'll report unexplained or severe bruising to my doctor right away." Which finding should a nurse identify as requiring further investigation? 1. R d bl od cell (RBC) count of 4.9 million/μl 2. Platelet count of 115,000/μl 3. White blood cell (WBC) count of 7,000/μl 4. H mato rit of 45% When following standard precautions, a nurse's primary responsibility is to: 1. wear gloves for all client contact. 2. consider all body substances potentially infectious. 3. place a body substance isolation sign on the client's door. 4. wear gloves and a gown if the client is in respiratory isolation. A client with severe shortness of breath comes to the emergency department. He tells the emergency department staff that he recently traveled to China for business. Based on his travel history and presentation, the staff suspects severe acute respiratory syndrome (SARS). Which isolation precautions should the staff institute? 1. Droplet precautions2. Airborne and contact precautions 3. Contact and droplet precautions 4. Contact precautions A nurse is collecting a health history on a client who's to undergo a renal angiography. Which statement by the client should be the priority for the nurse to address? 1. "I've had diabetes for 4 years." 2. "I'm allergic to shellfish." 3. "I haven't eaten since midnight." 4. "My physician diagnosed me with hypertension 3 months ago." Which finding best indicates that a nursing assistant has an understanding of blood glucose meter use? 1. Verbalizing an understanding of blood glucose meter use 2. Documenting a normal blood glucose level 3. Providing documentation of previous certification 4. Demonstrating correct technique A nurse prepares to assess a client who has just been admitted to the health care facility. During assessment, the nurse performs which activity? 1. Collects data 2. Formulates nursing diagnoses 3. Develops a care plan 4. Writes client outcomes A client is being discharged with a home oxygen delivery device. Which comments indicate that the client understands safety regarding home oxygen? Select all that apply. 1. "No one can smoke within 10′ of the oxygen." 2. "I can carry my oxygen in a bag for easy portability." 3. "I need to keep my oxygen away from electrical sources." 4. "I should keep my oxygen away from direct heat." 5. "I'll keep my oxygen out of the sun in all circumstances."A client newly admitted to a psychiatric inpatient setting demands a soda from a staff member who tells him to wait until lunch arrives in 20 minutes. The client becomes angry, pushes over a sofa, throws an end table, and dumps a potted plant. Which goal should a nurse consider to be of primary importance? 1. Talking with the client's family about his angry feelings 2. Performing an assessment for tardive dyskinesia 3. Learning to effectively express needs to staff and others 4. Demonstrating control over aggressive behavior A nurse assists in writing a community plan for responding to a bioterrorism threat or attack. When reviewing the plan, the director of emergency operations should have the nurse correct which intervention? 1. All personnel should wear protective clothing, including a gown, gloves, and respiratory protection. 2. Clients exposed to anthrax should immediately remove contaminated clothing and place it in the hamper. 3. Clients should be instructed to wash thoroughly with soap and water. 4. Access to the area should be restricted. A client in a late stage of acquired immunodeficiency syndrome (AIDS) shows signs of AIDS-related dementia. Which nursing diagnosis takes highest priority? 1. Bathing or hygiene self-care deficit 2. Ineffective cerebral tissue perfusion 3. Complicated grieving 4. Risk for injury Several children in a kindergarten class have been treated for pinworm. To prevent the spread of pinworm, the school nurse meets with the parents and explains that they should: 1. tell the children not to bite their fingernails. 2. not let children share hairbrushes. 3. tell the children to cover their mouths and noses when they cough or sneeze. 4. have their children immunized. A client who has diabetes mellitus and has sustained a large laceration on her left wrist asks the nurse, "How long will it take for my scars to disappear?" Which statement is the nurse's best response?1. "The contraction phase of wound healing can take 2 to 3 years." 2. "Wound healing is very individual but the scar should fade within 4 months." 3. "With your history and the type and location of your injury, it's hard to say." 4. "If you don't develop an infection, the wound should heal in 1 to 3 years." A client who's 4 weeks pregnant comes to the clinic for her first prenatal visit. When obtaining her health history, the nurse explores her use of drugs, alcohol, and cigarettes. Which client outcome identifies a safe level of alcohol intake for this client? 1. "The client consumes no more than 2 oz of alcohol daily." 2. "The client consumes no more than 4 oz of alcohol daily." 3. "The client consumes 2 to 6 oz of alcohol daily, depending on body weight." 4. "The client consumes no alcohol." An obese client has returned to the unit after receiving electroconvulsive therapy (ECT). A nurse requests assistance in moving the client from the stretcher to the bed. Which direction should the nurse give to a nurse who volunteers to help? 1. "Obtain the sliding board or two other people to assist us." 2. "Get the hydraulic lift; the client is still groggy." 3. "Place the client in a semi-Fowler's position. Doing so will make the move easier." 4. "Place the client on his side; then use a drawsheet to bring him to the bed." A nurse is preparing to administer an I.V. containing dextrose 10% in ¼ normal saline solution to a 6-month-old infant. The nurse should select which tubing to safely administer the solution? 1. I.V. tubing with a volume-control chamber 2. I.V. tubing with a macrodrip chamber 3. I.V. tubing with a special filter 4. Standard I.V. tubing used for adults After surgery to repair a cleft lip, an infant has a Logan bow in place. Which postoperative nursing action is appropriate? 1. Removing the Logan bow during feedings 2. Holding the infant semi-upright during feedings3. Burping the infant less frequently 4. Placing the infant on the abdomen after feedings A nurse observes a nursing assistant bending over a bed as she helps an obese client sit up. The nurse discusses her observations with the nursing assistant to reinforce the need for proper body mechanics. Which response indicates that the nursing assistant understands these principles? Select all that apply. 1. "I need to keep my back straight and lift with my thigh muscles." 2. "I need to keep my elbows bent and use my thigh muscles to bear the weight." 3. "I should bend at the knees, keep my back straight, then pull the client up." 4. "I should stand at the client's side, grasp the drawsheet, and pull the client up." 5. "I should ask the client to help as much as possible." A physician orders digoxin (Lanoxin) elixir for a toddler with heart failure. Immediately before administering this drug, the nurse must check the toddler's: 1. serum sodium level. 2. urine output. 3. weight. 4. apical pulse. One aspect of implementation related to drug therapy is: 1. developing a content outline. 2. documenting drugs given. 3. establishing outcome criteria. 4. setting realistic client goals. A client is diagnosed with gonorrhea. When teaching the client about this disease, the nurse should include which instruction? 1. "Avoid sexual intercourse until you've completed treatment, which takes 14 to 21 days." 2. "Wash your hands thoroughly to avoid transferring the infection to your eyes." 3. "If you have intercourse before treatment ends, tell sexual partners of your status and have them wash well after intercourse."4. "If you don't get treatment, you may develop meningitis and suffer widespread central nervous system (CNS) damage." A client is admitted with bacterial meningitis. Which hospital room is the best choice for this client? 1. A private room down the hall from the nurses' station 2. An isolation room three doors from the nurses' station 3. A semiprivate room with a client who has viral meningitis 4. A two-bed room with a client who previously had bacterial meningitis A client in the emergency department is diagnosed with a communicable disease. When complications of the disease are discovered, the client is admitted to the hospital and placed in respiratory isolation. Which infection warrants airborne isolation? 1. Mumps 2. Impetigo 3. Measles 4. Cholera A client in early labor is connected to an external fetal monitor. The physician hasn't noted any restrictions on her chart. The client tells the nurse that she needs to go to the bathroom frequently and that her partner can help her. How should the nurse respond? 1. "Because you're connected to the monitor, you can't get out of bed. You'll need to use the bedpan." 2. "I'll show your partner how to disconnect the transducer so you can walk to the bathroom." 3. "Please press the call button. I'll disconnect you from the monitor so you can get out of bed." 4. "I'll insert a urinary catheter; then you won't need to get out of bed." A nurse is teaching a safety class for parents of preschoolers. Which injuries should the nurse include as common among preschoolers? Select all that apply. 1. Automobile accidents 2. Drowning 3. Pedestrian accidents 4. Fire5. Sexually transmitted diseases 6. Homicide A nurse is assigned to a client with acquired immunodeficiency syndrome (AIDS). When handling the client's blood and body fluids, the nurse uses standard precautions, which include: 1. wearing gloves to touch the client. 2. wearing a gown, gloves, and protective eyewear when obtaining a urine specimen via catheterization. 3. disposing of needles uncapped. 4. wearing gloves when instilling eyedrops. A client comes to the outpatient department complaining of vaginal discharge, dysuria, and genital irritation. Suspecting a sexually transmitted disease (STD), the physician orders diagnostic testing of the vaginal discharge. Which STD must be reported to the public health department? 1. Bacterial vaginitis 2. Gonorrhea 3. Genital herpes 4. Human papillomavirus (HPV) A nurse is assigned to care for a recently admitted client who has attempted suicide. What should the nurse do? 1. Search the client's belongings and his room carefully for items that could be used to attempt suicide. 2. Express trust that the client won't harm himself while in the facility. 3. Respect the client's privacy by not searching his belongings. 4. Remind all staff members to check on the client frequently. Which use of restraints in a school-age child should the nurse question? 1. To substitute for observation 2. To ensure the child's comfort or safety 3. To facilitate examination 4. To aid in carrying out proceduresA nurse is caring for a client with a long-term central venous catheter. Which care principle is correct? 1. Use clean technique when accessing the port with a needle. 2. If the needle becomes contaminated before accessing the port, clean the needle with povidone-iodine solution. 3. Clean the port with an alcohol pad before administering I.V. fluid through the catheter. 4. If unsuccessful with the first attempt to access the catheter, reuse the needle and try again. A nurse is teaching parents about accident prevention for a toddler. Which guideline is most appropriate? 1. Always make the toddler wear a seat belt when riding in a car. 2. Make sure all medications are kept in containers with childproof safety caps. 3. Never leave a toddler unattended on a bed. 4. Teach rules of the road for bicycle safety. A client is transferred from the emergency department to the locked psychiatric unit after attempting suicide by taking 200 acetaminophen (Tylenol) tablets. The client is now awake and alert but refuses to speak with the nurse. In this situation, the nurse's first priority is to: 1. establish a rapport to foster trust. 2. place the client in full leather restraints. 3. try to communicate with the client in writing. 4. ensure safety by initiating suicide precautions. After administering an I.M. injection, a nurse notices there isn't a sharps-disposal container nearby. Which action should the nurse take? 1. Hold the barrel of the syringe in one hand. With the other hand, push the cap into place over the needle. 2. With one hand, use the needle to scoop up the cap. Holding the barrel in one hand, carry the syringe to the closest sharps-disposal container. 3. With one hand, use the needle to scoop up the cap. Holding the barrel in one hand, carry the syringe to the closest trash container. 4. Hold the barrel of the syringe in one hand. With the other hand, push the cap intoplace over the needle. Carry the syringe to the closest sharps-disposal container. While repositioning an immobile client, a nurse notes that the client's sacral region is warm and red. Further assessment confirms that the skin is intact. Based on these findings, it's most appropriate for the nurse to: 1. do nothing; the client's skin is intact. 2. give the client a donut ring to reduce pressure on the affected area. 3. contact the client's family. 4. document the condition of the client's skin. A nurse is demonstrating umbilical cord care to a client who recently gave birth. Which actions should the nurse teach the client to perform? Select all that apply. 1. Keep the diaper below the umbilical cord. 2. Tug gently on the umbilical cord as it begins to dry. 3. Apply antibiotic ointment to the umbilical cord twice daily. 4. Only sponge bathe the neonate until the umbilical cord falls off. 5. Clean the length of the umbilical cord with alcohol several times daily. 6. Wash the umbilical cord with mild soap and water. Which nursing intervention is most appropriate if a client develops orthostatic hypotension while taking amitriptyline (Elavil)? 1. Consulting the physician about substituting a different type of antidepressant 2. Advising the client to sit up for 1 minute before getting out of bed 3. Instructing the client to halve the dosage until the problem resolves 4. Informing the client that this adverse reaction should disappear within 1 week A client is diagnosed with herpes simplex. Which statement about herpes simplex infection is true? 1. During early pregnancy, herpes simplex infection may cause spontaneous abortion or premature birth. 2. Genital herpes simplex lesions are painless, fluid-filled vesicles that ulcerate and heal in 3 to 7 days. 3. Herpetic keratoconjunctivitis usually is bilateral and causes systemic symptoms. 4. A client with genital herpes lesions may have sexual contact but must use acondom. A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene? 1. Do nothing until the chemical agent is identified. 2. Irrigate the wounds with water. 3. Wash the wounds with soap and water and apply a barrier cream. 4. Insert a 20-gauge I.V. catheter and infuse normal saline solution at 150 ml/hour. To collect a clean-catch midstream urine specimen from a female client, the nurse instructs her to clean the area at the external urinary meatus with an antiseptic. How should the client clean the area? 1. By swabbing the labia minora from front to back 2. By cleaning the labia minora from back to front 3. By cleaning the labia majora from back to front 4. By swabbing the entire perineal area A client with respiratory complications of multiple sclerosis (MS) is admitted to the medicalsurgical unit. Which equipment is most important for the nurse to keep at the client's bedside? 1. Sphygmomanometer 2. Padded tongue blade 3. Nasal cannula and oxygen 4. Suction machine with catheters A nursery nurse performs an assessment on a 1-day-old neonate. During the assessment, the nurse notes discharge from both of the neonate's eyes. The nurse should take which step to help determine whether the neonate has ophthalmia neonatorum? 1. Do nothing; discharge is a normal finding in the eyes of a 1-day-old neonate. 2. Notify the physician immediately. 3. Ask the physician for an order to obtain cultures of both of the neonate's eyes. 4. Obtain a nasal viral culture.A nurse is planning care for a client with human immunodeficiency virus (HIV). She's being assisted by a licensed practical nurse (LPN). Which statements by the LPN indicate her understanding of HIV transmission? Select all that apply. 1. "I'll wear a gown, mask, and gloves for all client contact." 2. "I don't need to wear any personal protective equipment because nurses have a low risk of occupational exposure." 3. "I'll wear a mask if the client has a cough caused by an upper respiratory infection." 4. "I'll wear a mask, gown, and gloves when splashing of body fluids is likely." 5. "I'll wash my hands after client care." A client is experiencing dryness in the nares while receiving oxygen via nasal cannula at 4 L/minute. Which medication should the nurse apply to help alleviate the dryness? 1. Petroleum jelly 2. Sterile water 3. Lubricant jelly 4. Antibiotic ointment After a motor vehicle crash, a client is admitted to the medical-surgical unit with a cervical collar in place. The cervical spinal X-rays haven't been read, so the nurse doesn't know whether the client has a cervical spinal injury. Until such an injury is ruled out, the nurse should restrict this client to which position? 1. Flat 2. Supine, with the head of the bed elevated 30 degrees 3. Flat, except for logrolling as needed 4. A head elevation of 90 degrees to prevent cerebral swelling A client with chronic progressive multiple sclerosis is learning to use a walker. What instruction will best ensure the client's safety? 1. "Place the walker directly in front of you and step into it as you move it forward." 2. "When you move the walker, set the back legs down first. Then step forward." 3. "Maintain a firm grip on the front bar as you step into the walker." 4. "Use a walker with wheels to help you move forward."A nurse is preparing to perform a physical examination on a postpartum client. The client asks the nurse why gloves are necessary for the examination. What is the nurse's best response? 1. "Gloves help protect you against infectious organisms." 2. "Gloves guard you against my cold hands." 3. "Gloves may protect me against infectious organisms." 4. "Gloves are required for standard precautions." A client asks how long she and her husband can safely continue sexual activity during pregnancy. How should the nurse respond? 1. "Until the end of the first trimester." 2. "Until the end of the second trimester." 3. "Until the end of the third trimester." 4. "As long as you wish, if the pregnancy is normal." After an infant undergoes surgical repair of a cleft lip, the physician orders elbow restraints. For this infant, the postoperative care plan should include which nursing action? 1. Removing the restraints every 2 hours 2. Removing the restraints while the infant is asleep 3. Keeping the restraints on both arms only while the child is awake 4. Using the restraints until the infant recovers fully from anesthesia A client is newly diagnosed with Alzheimer's disease. When planning this client's care, the nurse should focus on: 1. helping the client recognize his physical limitations. 2. helping to reverse the disease. 3. providing a safe, structured environment. 4. preventing loss of the client's cognitive functions. [Show More]

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